Tuesday, October 11, 2016

How to Resist Psychiatric Injustice on National Coming Out Day

By Jess Stohlmann-Rainey

Today is National Coming Out Day. I remember the first time I was excited about this day. It was my first year of college, and I felt so liberated from my oppressive and traumatic high school experience. It was the first time I thought I could be proud about my identity and be supported by the community around me. I felt like I had left discrimination in the dust when I moved away. As it turns out, I had some prescription strength rose-colored glasses on, but I wouldn’t trade that feeling for the world.

Later that same year, I had my first encounter with a therapist who blatantly treated my sexuality like the root cause of all my problems. I had experienced some bad providers before, one who even told me I may not be able to hold a job or move out of my parents’ home. This was different, and worse. This therapist seemed to believe that a fundamental piece of my identity might cause me interminable pain. The most unbelievable part of it is that this person considered themselves an ally, and even had a Safe Zone sign plastered on the wall. At the time, I wrote all of this off as an individual problem with this therapist. Now I know better.

The mental health system has a sordid history, and that history is intertwined in current practice. It is particularly sordid for queer people. (Whoa – why are you using the word queer?) Those of us who work in mental health and suicide prevention do a pretty bad job of acknowledging this history and apologizing for it. I get it, it isn’t easy to admit when you’ve screwed up. It is particularly hard when the screw up destroyed people’s lives. The problem with not acknowledging and apologizing is that it denies the very real experiences of people being harmed by the system. That’s called gaslighting, folks. While it might make the mental health community feel better, it completely obliterates the ability to address the last vestiges of this painful history – very real, very destructive discrimination.

A History Lesson

I could write volumes about the history of queer people’s interactions with the mental health system, but I won’t. There is an even deeper dive than what I am going to discuss here.


For the first time, queer identities enter into the mental health scene. During this period of time, queer identities are pathologized and criminalized, and “therapies” are utilized to try to eliminate people’s queerness, but end up just attacking their humanity. The myth that queer people are crazy, dangerous, and criminal, upheld by the mental health community, is leveraged to ban queer people from entering the country and joining the military.
  • LGB identities are characterized as pathologies, associated with psychopathy and criminal behavior
  • Trans* identities are considered sexual pathologies
  • Frontal lobotomy and electroshock therapy are recommended treatments for queer people
  • Queer people are banned from entering the country and from the military because they are “dangerous”

During this time period, queer people are further pathologized, although the type of pathology shifts around some.  The Diagnostic and Statistical Manual of Mental Disorders enters the scene, serving as a teaching tool and guiding manual for all providers. The DSM includes queer identities as disorders and painful, harmful therapies are recommended treatments.
  • Trans* identities are associated with psychopathy
  • DSM categorizes homosexuality as a sociopathic personality disorder, then as a personality disorder
  • Pharmacological aversion therapy and electroshock therapy are recommended treatments for queer people

Lots of progress was made toward the end of deinstitutionalization. This was a time of progress for many marginalized people. The major mental health associations and institutions got on board with progress, but didn’t do much in terms of reparations or apologies.
  • Sodomy laws repealed in many states
  • Queer people represented at American Psychiatric Association
  • Activists work to increase protective factors in the queer community 

In the last twenty years, there have been great strides in rectifying some of the blatantly discriminatory practices. Some of the biggest wins are below.
  • Homosexuality removed from the DSM
  • Don’t Ask, Don’t Tell compromise instituted and repealed
  • American Psychological Association condemns conversion therapy, supports marriage equality and second-parent adoption
  • Sodomy laws ruled unconstitutional
Photo by Daniel Watson
If you just look at the wins, the last twenty years look pretty good. Unfortunately, the remnants of this difficult history still impact people’s lives today. There are no national standards requiring that mental health providers receive training about the unique needs of queer populations. Gender confirmation surgery, hormone therapy, etc. require a mental health diagnosis and treatment for insurance coverage. Medicare/Medicaid require that consumers receive a diagnosis to qualify for treatment. The leading cause of death among queer people age 10-24 is suicide. Conversion therapy is still legal in the United States.

It’s a setup. Queer people are systematically excluded from high-quality care, and because we don’t get what we need, we struggle. The struggle is often used to pathologize our identities further, creating a vicious cycle. We are treated by mental health professionals who are untrained and unprepared to work with us. We are stigmatized both as consumers and as queer people. We are over-diagnosed with some conditions, underdiagnosed with others. Data collection is not inclusive of queer people or does not ask demographic questions necessary to become inclusive. Diagnostic studies rarely consider queer identities as a factor. We are highly likely to be exposed to trauma. Minority stress increases the severity and frequency of our mental health symptoms, and marginalization interferes with connectedness – the cornerstone of suicide prevention.

Getting What You Need in a Broken System

The system is clearly broken, but for now, it is the one we have. As a queer person, working in suicide prevention, with 15+ years of mental health services under my belt, I have developed a few tricks to get what I need when the system isn’t enough.

Make Your Good Practice Checklist

I developed my checklist so that I could look at a website, make a phone call, and/or walk into the waiting room without paying a copay and decide whether or not I should give providers a chance to work with me. Everyone’s list could look a little different, but here are some ideas of what you might include.
  • Non-discrimination policy
  • Inclusive intake forms
  • Inclusive restrooms
  • Inclusive language
  • Queer people represented on website/print materials/office

Interview Your Provider

Anyone who has experienced an intake knows how rough that process can be. The problem with intakes for me is that they put all the power in the provider’s hands. My way of leveling the playing field is to refuse to do an intake until I have gotten to interview providers. The types of information I look for are: the provider’s attitudes about queer people and my diagnosis, their experience with people like me, how they make therapeutic decisions, their approach to forced treatment, how many people they have put on a 72 hour hold, and what training they have had. Here [JS1] is a handy list of some sample questions I have developed with some peers.
Photo by Sharon Pittaway

Find Alternative and Additional Pathways to Recovery

Traditional mental health treatment is not the only path to recovery, and isn’t right for everyone. I have been both helped and hurt by the traditional mental health system, so a combination of traditional services and alternatives ended up being the right route for me. Some alternatives to consider are: mindfulness, volunteering, activism, dance/movement therapy, art/music therapy, sobriety, getting outside and doing nature things, peer support, spirituality, massage, acupuncture, and homeopathy.

Link Up with Your People

I can’t say enough about the benefits of finding people like you to support you through dark times, share their wisdom, and lift up your voice when you speak truth to power. Finding my people has been integral to my wellness.

Making Queer Spaces Inclusive

While we are working on changing the system, we can also make our queer spaces better. Often times, queer spaces are not intentionally designed to support queer people who experience mental health challenges. To make our spaces better, we can:
  1. Provide mental health resources
  2. Advocate for education for mental health providers
  3. Educate our groups about mental health and accessing care
  4. Advocate for parity
  5. Offer dry/sober activities outside of recovery meetings
  6. Train our constituents and leaders in mental health and suicide prevention

Making the System Better

System change is slow and challenging. One of the best ways to influence system change is to educate the people within the system to push back. Seven things mental health providers can do to improve the system
  • Educate yourself about queer issues
  • Advocate for national training standards about queer identities and issues
  • Do not practice conversion therapy and advocate that it be outlawed
  • Do not conflate queer identities with disorders, pain, or suffering
  • Use identity affirming intake paperwork
  • Represent queer people in your advertising, website, and office
  • Recognize and celebrate queer holidays and remembrance days
In honor of National Coming Out Day, I want to invite my peers in suicide prevention and mental health to challenge themselves. Learn and grow. Do not let the history or our institutions define us. It is our responsibility to make the world a safer place for people to come out.

In her book, Daring Greatly, Brene Brown says: “Courage starts with showing up and letting ourselves be seen.” Congratulations to all my queer family who are daring greatly today.

·         How is social justice incorporated into your practice?
·         Have you worked with suicidal clients or attempt survivors before?
·         What kind of services do you think suicide attempt survivors typically need?
·         Have you worked with clients who are generally well, but use services for maintenance?
·         What types of therapy do you use most often?
·         Do you have specific training about behavior therapy? What training? When?
·         Have you had specific training about suicide? What training? When?
·         What does it mean for your clients to be well?
·         When do you think someone should be done with therapy?
·         What do you do when you think a client is lying or avoiding certain issues?
·         How many clients have you put on an M1/72 hour hold?
·         What is the process of putting a person on that hold?
·         When you have put people on a hold, have they come back to you for treatment?
·         What do you do to ensure your client’s dignity while they are in your care?
·         What types of concerns/conditions do you think you are best at treating?
·         Have you treated clients in interracial relationships? What unique challenges do they face?
·         Have you treated clients who are bisexual? What unique challenges do they face?
·         Have you treated people who work in the mental health field? What challenges do they face?
·         Have you treated clients who are substance users? What unique challenges do they face?
·         Do you use a harm reduction approach?
·         Have you worked with clients with severe and persistent or recurring suicidal intensity?
·         What has your experience working with people who have Borderline Personality Disorder been like?
·         What are deal breakers that would lead you to terminate treatment?
·         What is your strategy for developing a treatment plan?