They/Them pronouns. Use them. Love them.

I was one of you. I didn’t “get it”. I didn’t understand the they/them identification and I thought it was confusing. Am I referencing one person or multiple?

Then I had my first non-binary client. Then my second. Now many. Now I get it. Now I interrupt people who say they “don’t get it and think it’s stupid” and tell them they are wrong and here’s why.

I am a firm believer in not passing judgement. It took me some time to get there in my life, but for the past five years at least I’ve been there. I’ve opened myself up to new experiences and new people and learned so much. Psychiatry does that. Makes you discover new things about people every day, makes me examine my beliefs and values regularly.

So back to they/them. It is the pronoun most often preferred by the non-binary community. Not always but often. I’ve had non-binary clients on hormone replacement therapy (of Testosterone or Estradiol or both at different times for different reasons). I’ve had non-binary clients seek surgical interventions. I’ve had them not. I’ve had non-binary clients look probably very confusing to society in general, but bless them, they present themselves as they feel comfortable and as they see fit with fear yes of judgement and discrimination but the courage to walk forth anyway.

The non-binary community specifically has taught me so much about courage. For many transgender individuals instead of ascribing to their birth gender they identify more with the opposite gender- boy to girl or girl to boy. That seems more acceptable to society sometimes. They still face horrible discrimination and assaults and even murder, but the binary view society holds of gender is easier to wrap one’s head around.

A non-binary individual may not feel as though they belong to either gender and in fact may seek different traits from both genders. They feels more like a “they” then a “him” or a “her”. They may feel more comfortable being pegged as a certain gender he/him or she/her in general but still feel more comfortable with they/them.

They may want Testosterone to lower their voice, and estradiol to grow breasts. They may identify as asexual, or they may identify as pansexual or gay or Queer or heterosexual. Just a blatant reminder that gender identify has nothing to do with sexual orientation.

I have a lot of “they/them” individuals on my caseload. They are wonderful people who teach me so much about gender biases and gender expectations as they break all of them. After having been privileged to be a witness to their journey through the gender spectrum I know that there is so much I don’t know.

I know though that there truly are they/them individuals who do not fit one gender or the other, and I see the toll it takes on them to have to explain that over and over to family members, friends, and every one else they come into contact with. I see the hurt and frustration when some one calls them a her, when they have asked for the hundredth time to be referred to as they.

I see you. I know you. And I admire you.

If you know a they/them don’t be repelled by your insecurities and by your lack of knowledge. Just respect the request for appropriate pronouns. Get to know them. Because once you do, you will realize that your gender binary norms are wrong. That there are individuals who defy them. That they are beautiful and deserve respect.

So yes, they/them feels weird at first. Just do it. Because it’s not hurting you. But it’s hurting them deeply by not using it.

Dear Parents of Lesbians, Gays, Bisexuals, Transgender, Non-binary, and Queer Individuals,

It’s not a phase.

You will lose you children if you do not accept them for who they are and what they are telling you.

By the time they come out to you they’ve been having these thoughts/feelings for at least a year and likely have experimented with presenting in whatever way they feel is authentic.

When I say you will “lose” your children I mean many things: they will move out, they will stop speaking to you, they will become homeless turn to drugs instead of living in a non-welcoming/accepting/loving environment, and they might kill themselves and actually die.

I treat many LGBT individuals from young adolescents to people over the age of fifty. I am not trying to scare you I am simply stating the reality of the situation.

They yearn for your acceptance. They remember every nuance of the conversation when they first came out to you. They remember every time you’ve shown disgust toward them. They remember every time you’ve shown them love and acceptance. Even those who have been estranged from parents for years still hope against hope to reconnect and be accepted and loved by their Mom and Dad.

Every holiday, every Mother’s Day, every Father’s Day, every time they see some one who looks/smells/acts like you they think of you. They talk about you in therapy. They cry about you, they yell about you, and so much more. Even after you have passed away and they have children or grandchildren of their own, they remember and they tell their story about their parents.

Specifically to the parents of transgender or non-binary individuals…I know this is a lot to wrap your head around. You will mourn the loss of your son or daughter as they evolve into their new individual self. You will mourn the loss of the name that you likely painstakingly chose. But the pain you experience is only a fraction of the fear, the emotional pain, and the physical pain that your child will feel during their gender journey. They are facing a lifetime of discrimination and permanent alterations to their body that are often painful. They are facing being physically assaulted, sexually assaulted, and even murdered for presenting as who they are. While you certainly are entitled to feel any way you want, this is not about you. When you are with them it’s about them. Be present with them. Love them. Do your own work with your own therapist away from them. Talk to trusted friends or family members, join support groups, but also know this about your child.

At the end of the day your children are the bravest people I know. They are living in a manner that is true to them in a society that is not always accepting, and can be downright hostile.

Listen to your child. Learn from them. Love them. Admire them as I do. Move forward with them. Otherwise you will lose them.


An LGBT Therapist

Treating Gender Questioning Clients for Clinicians

When I initially obtained my bachelors in nursing in 2007 I don’t recall learning about transgender individuals at any point in my four year program. During my Master’s program I think we had some discussions around the LGBT community in generalized terms but nothing specific to therapy with clients who are gender questioning. I graduated in 2012, and started practicing as an psychiatric nurse practitioner in 2013. At some point I had my first transgender patient on the inpatient psychiatric unit I worked on. Inpatient treatment is very different than outpatient. Inpatient is focused on stabilization and it’s not the place to go into deep gender work. Transgender or non-binary clients were usually there for a primary depressive or bipolar illness that was or was not related to their gender identity. Our focus was on stabilizing symptoms of depression or bipolar disorder, not on gender identity.

Along the way I slowly transitioned to outpatient medication management and transgender clients slowly and naturally made their way onto my caseload for medication management. Medication management has an element of detachment from the primary gender work. For medication management we still focus on symptoms that can respond to medication- depression, anxiety, etc. I always have the discussion about gender identity and how body image, hormone therapy, surgery accessibility, etc. is contributing or not to dysphoric or mood symptoms but it’s really focused on symptom management.

During these years I started to educate myself. I found gender work even in the removed role of managing medication, to be interesting and rewarding. These clients are vulnerable and brave, and I very much enjoyed the work with them. But I knew my knowledge was lacking and I started to have gender questioning people asking me to do individual therapy in addition to medication management.

I did not take on a client who was newly questioning their gender until I felt competent enough to provide quality care. I went to conferences, I read books, I talked to people. I talked to clinicians professionally. I talked to transgender individuals who I knew personally and professionally and with a great deal of sensitivity I asked them if they would tell me what worked for them and what didn’t when interacting with mental health providers. I asked what they would look for in a healthcare provider. I asked my LGBT group their good and bad experiences with healthcare providers. I read studies dating as far back as the 80’s. I ate up and continue to eat up information. I also got supervision. When I started therapy with my first gender questioning client I felt I had a solid base of knowledge and a solid support net of people to call if anything came up that I didn’t know how to handle.

What I discovered is that I still loved doing gender work, and even more so as the individual therapist not just providing medication management. I’ve described gender work to people as this- being the most neutral person imaginable for my client. Gender work is unique in therapy. Because the goal of individual therapy for someone with depression is to help them feel less depressed. Same with anxiety or PTSD symptoms. The goal is to reduce symptoms. But with gender work the therapist should not be guiding a person toward one gender or another.

The therapist can be a blank slate providing a safe space for a person to explore their own gender identification without judgement and without the boundaries of the binary societal view of gender. It involves exploring self image, self esteem, sexual orientation, mood, persistent thoughts, family systems, what gender means to them, what gender feels like to them, how gender can be a spectrum and that their journey can be whatever they want it to be. I’ve found that so much of the work for gender clients is providing them their own empowerment in defining their own sense of self.

As a health care provider there is generally a sense that we should present this front that we know what we are doing. I agree with that to a degree. I think to be a good health care provider we also need to know what we don’t know and be comfortable with that. I would not do individual therapy with a young child questioning their gender because I do not have the training or experience to provide competent care. I did not do individual therapy with children prior to branching into gender work, so I don’t have a foundation for that age group in general.

For a young adult or adult questioning or newly transitioning I do feel comfortable providing individual therapy and medication management. But I didn’t just wake up and feel that way. Gender work is a sub-specialty and should be treated as such. It required me to challenge myself as a provider but it has been incredibly rewarding to see clients through this intimate and courageous journey.

I would advise any clinician with interest in this area to not just start marketing yourself as a gender specialist. Really do the work. Start with one client. Do that work well. Learn from it. Take on another. Build slowly, and never stop learning and asking and seeking supervision from others with more experience. Pick a number of CEU’s per year that you will commit to gender education. As a psychiatric nurse practitioner we are required to do 25/year, I commit at least half to gender continuing education. And at the end of each day identify your limitations and don’t be afraid to refer a client out if you do not have the skillset. Clients are not educational opportunities they are people, and they deserve the best care possible for what they are going through.

Five Signs Therapy is Working

Therapy is a process. I should get that tattooed on my head.

My favorite poster in one of my offices says, “I’m not telling you it’s going to be easy, I’m telling you it’s going to be worth it.”

I’ve had clients not even notice that poster until about three or four months in. Then they smile and say something like, “Truth.”

My ideal therapy client has trauma, low self esteem, and likely some anxiety and depression to top it off. Through therapy and often medication management combined, we explore painful memories which have led to current behavior and communication patterns which lead to challenges in life. The point of therapy is to recognize unhealthy behavior patterns and undo them.

This is generally how I know therapy is helping my clients about six months in.

  1. They are now happy to see me and actually come into my office smiling. The first couple months when we really get into heavy work clients will come in looking angry and irritated and tell me that they really didn’t want to come to see me because it’s so damn draining and they don’t know why they put themselves through this every week. I calmly smile and congratulate them for coming and promise to go easy this week. After two-six months of this heavy work though the load should start to lighten. Clients may start to look forward to seeing me because they are starting to feel better. They are recognizing positive changes and we may even be able to cut down to every other week. This is a gross generalization, but I’d say most people could start noticing improvements around the six month mark.
  2. Whatever brought them to therapy, when I ask them how it’s going, is not even on their radar. It could have been a break-up, ongoing stress in their marriage, stressed relationships with parents or children, addiction, work stress. Whatever was identified as the initial problem has taken a back seat because the work they’ve done on themselves has started seeping into other aspects of their life in a positive manner.
  3. They’ve achieved a goal. Perhaps when they started seeing me they didn’t know how to drive as a young adult (it’s more common in these days of Uber than one might think) or they didn’t have a passport, they were flunking out of school or not even enrolled, or they had never filed taxes. Intense tasks that are part of life that had been continuously put on the back burner or seen as unattainable. Now six months later perhaps they are enrolled in driver’s education classes or they have their permit, or their grades came up to B’s this semester, or they are enrolled for next year. Usually not all of these things, but at least one area has seen a large step taken.
  4. Relationships with others are noticeably improved to my client and to the people around them. Or on the flip side for the first time in their lives they have cut a toxic person out and it feels good to them. If a client is doing the work inside and outside of our sessions then they are seeing chronic unhealthy communication patterns and working actively on changing them. This is being modeled within therapy and being utilized in their every day lives.
  5. My client says they feel better and the person sitting in front of me today is a far cry (sometimes literally) from the person who sat there six months ago. That’s not to say our work is done. But the client feels and presents as lighter. I can challenge them more intensely on behaviors and communications without them falling apart. I can push them more in session and they can push themselves more outside of session. Then comes that glorious moment when I say, I think we can cut down to every other week.

This is probably the only job where the goal for the therapist is to be “Fired” by our clients. The goal is for a person to improve so they need less treatment, and more time in their healthy and happy lives. Therapy is not easy and anyone who has been through it can tell you that it downright sucks at times but the light at the other end is gratifying for both the therapist and the client.

Supporting Women with Infertility

There are multiple aspects to infertility, multiple treatments, and also failures. There are roughly three stages to infertility that I have observed in practice- diagnosis of infertility, treatment of infertility, and post-treatment which results either in a baby or not. All three of these stages have unbearable pain emotionally and physically for women. All stages stress marriages and partnerships, and all stages are potentially financially stressful as well.

Diagnosis of infertility for heterosexual couples can occur after one year of trying to conceive without success. Diagnosis of infertility in homosexual couples varies. For lesbian couples it is defined often by insurance companies. For example most will only cover In vitro fertilization (IVF) (if there is infertility coverage at all) after at least three failed Intrauterine inseminations (IUI). Some insurance companies require up to five or more failed IUI’s though. IUI and IVF informal definitions can be found here.

To have gone through potentially a year of trying to conceive before having medical intervention and diagnostic testing done is emotionally draining. If in that year there is a miscarriage it is even worse. If in that year you turn forty or forty-one then women start to despair and feel they will never conceive because they are running out of time biologically. Before a woman or couple can be given the infertility diagnosis they are already stressed to the max, possibly depressed, possibly anxious, and potentially grieving a miscarriage or more than one miscarriage. To be given the diagnosis in order to have testing done and paid for by health insurance companies is often a relief for women and couples.

Testing takes time though. Time off from work. Infertility tests can be exceptionally painful for women especially if there is an underlying medical condition like endometriosis. If a woman has any sexual trauma these tests can be quite triggering of PTSD symptoms.

After the tests are completed which may or may not have been covered by health insurance, comes the diagnoses. Then there are difficult choices to be made. All to be decided as a couple with the fertility specialist that they are working with. These decisions can have lifelong implications in a marriage emotionally and financially.

Decisions are made. Steps are taken to either proceed with interventional methods of conception which can include hormones, injections, and more emotional and potentially physical stress. Then there is waiting for pregnancy test results. Receiving results, positive or negative. If positive there is joy, but also fear, will there be another miscarriage? Is it twins or triplets due to any of the medical interventions? If negative, will there be another cycle? Will there be more hormones and more stress.

Women struggling with infertility often tend to pull into themselves and isolate. They may disengage from social media to avoid seeing happy families with children. They can be depressed because of infertility itself or secondary to hormonal treatments. There can be severe anxiety associated with even entering the fertility doctor’s office if they have been working together for a long time with poor results. There is always hope sprinkled in with moments of deep despair.

Women may present for mental health treatment at any time during their journey. They may need one session only, or several. They may want to do couples work. They may want to not talk at all about infertility or they may just want to cry. I’ve seen the full spectrum in my office. I’ve also seen women on the other end of the journey. Some with children and some without.

What I have seen in women struggling at any stage of their journey is strength coupled with shame. Hope coupled with fear. Deep longing coupled with detachment. Isolation is probably the most common denominator. It’s not something as a society we talk about or support one another around.

If you are struggling with infertility reach out for help. Therapy can help. Having a space to cry, laugh, or just be without pressure or expectation can be helpful. It may be beneficial to create a space in couples work for your relationship as you embark or continue on this journey together. Wherever you are in the journey don’t be afraid to reach out for help.

Family Estrangement

When I started working in healthcare I never expected to see the number of people who are estranged from family members as I have encountered. It’s honestly more common for me to meet clients who are estranged from at least one family member than to meet clients who have completely intact familial relationships.

In my own clinical experience I’ve heard countless reasons for family estrangement: “They are toxic,” “It’s better for us to be apart,” “They only bring drama…” There can be emotional abuse, physical abuse, sexual abuse, or problems that arise over time like finances, inheritances, deaths, properties, custody, stepparents or stepchildren, etc. I wouldn’t say I’ve heard it all, because I haven’t, but I have heard a lot.

As a naive twenty year old in nursing school I remember introductory psychiatry and discussions around reparation and healing relationships. What I’ve learned over a decade in practice is that some relationships cannot be mended and that some individuals heal more fully with the absence of certain family members.

Possibly the most painful separations for clients to experience and recount are the loss of parent-child relationships. As the parent or the child. None of these estrangements happen quickly, and none happen easily. It is a long, painful process that starts often before either person is aware the distancing is happening. There is usually a final argument around something that has been continuously an issue or statement for years. But underneath there can be years of invalidation.

Clinically I often see the old adage “Hope springs eternal” come into play. Individuals chronically hope for change in relatives that often never comes to fruition leading to cut-off’s.

The opposite of estrangement is healthy family relationships in a tight knit family unit. Healthy relationships provide support, empathy, communication and love. Study after study finds that healthy families spend quality time together, which explains the chronic push for “family dinners” or “game nights” and put the phones away. These are tried and true methods to have daily or weekly quality time together. If there have been years of damage done then family dinners or outings likely will not fix it and the best medicine for estrangement is prevention.

But when estrangement is inevitable and you feel it is best for you in that moment then be at peace knowing you are doing what is right for you. When you think of that family member or members it may cause a feeling of pain or hurt because it is a loss. But if life is better for you, easier, emotionally more stable, if you feel a sense of relief living with estrangement then feel safe embracing it. Feel safe and comforted in the knowledge that you are not alone. There are many people and families with estranged family members.

Fill your life with love and laughter and feel justified to put up boundaries against pain and emotional turmoil.

I often share the following list with clients who suffer from feeling invalidated and not heard by family members or friends. This is taken from Dialectical Behavior Therapy Skills Workbook, by Mckay et al. and adapted from McKay et al. 1983.


  1. You have a right to need things from others. 
  2. You have a right to put yourself first sometimes.
  3. You have a right to feel and express you emotions or your pain. 
  4. You have the right to be the final judge of your beliefs. 
  5. You have the right to your convictions and beliefs. 
  6. You have the right to your experience- even if it’s different from other people’s.
  7. You have a right to protest any treatment or criticism that feels bad to you.
  8. You have a right to negotiate for change. 
  9. You have a right to ask for help, emotional support, or anything else you need.
  10. You have a right say no; saying no doesn’t make you bad or selfish. 
  11. You have a right not to justify yourself to others. 
  12. You have a right not to take responsibility for some else’s problem. 
  13. You have a right to choose not to respond to a situation. 
  14. You have a right, sometimes, to inconvenience  or disappoint others. 

You have a right to disentangle and disengage from people who are toxic to your life. You also have a right to try and re-engage at any time if that feels positive for you and your family.

Psychiatry is meant to be healing work. Sometimes to heal distance is required.

“If we begin to understand that relationships are not cages, that family is not a cage, we could release, and be released without suffering so deeply and profoundly.” Fiona McCall

This is not meant to rationalize irrational behavior. And is not meant to be substituted for putting work in to mend relationships if they can be mended. It is meant to bring peace in a moment when you may feel turmoil.

Seeking therapy and objective feedback is a great first step in exploring your own family dynamics and individual boundaries. Find someone you can connect with and who will validate your experience. And may you find peace.




The Power of Hope

Recently a client said to me they read something online, “Are you still fighting your demons or have you embraced them?” It was disturbing to my client because they realized in many ways what they thought was coping was actually a defense mechanism to continue maladaptive behaviors.

I am not a DBT therapist, but there are many concepts of DBT that I appreciate and pass onto clients. One of which is embracing the opposite behavior. When one feels they can’t get out of bed dialectics would say, do exactly the opposite of that behavior. Get out of bed. Commit to getting out of bed. It may be painful but that is an aside. Focus only on getting out of bed.

We all have demons and we all have dark holes that we wish we could just crawl into and never leave. What is it that allows you to crawl out of the dark and into the light? I have seen time and again in my clients that hope is sometimes all that get us through each minute and each hour.

What is hope? “A feeling of expectation for a certain thing to happen. A feeling of trust. A feeling of desire for something to happen.”

I would add to this definition and say, a feeling of trust that something we desire will happen. Human beings often have trust in the world or fate or God or whatever higher power you believe in, that something better will come. That the depression will ease, the anxiety will improve, that love will enter dark spaces.

Therapy unfortunately tends to lead clients through dark spaces, but it is with the intention of reaching the light on the other side. Harnessing hope through therapy can be incredibly powerful to witness and experience. I always tell clients, it may get worse before it gets better, but it will get better. I’ve had people tell me they hate coming to see me every week, but they still show up. Because on the other end, they do see improvement in their lives.

The idea of therapy is not just to work through problems and past trauma. The goal of therapy is to heal and to feel hope that today will be a better day.

To quote one of my heroes, Martin Luther King Jr.

“If you lose hope, somehow you lose the vitality that keeps life moving, you lose the courage to be, that quality that helps you go on in spite of it all. And so today, I still have a dream.” 

I like to think of therapy as helping guide people back to their own vitality and courage. Hope lives in us all, some people just need help accessing it.

Ten Signs You May Benefit From an Anti-depressant (for adults)

Many clients call for a medication evaluation after months or years of struggling with the decision to try psychiatric medication. You may have thought “I just need to suck it up,” “So many people have it worse” “I can just power through”. You may have been told by therapists over the years that you could benefit from psychiatric medication, “But I work, I have a family, I’m functioning. I’m fine. I don’t have time. etc.” The following are ten common reasons patient’s present for medication assessments.

  1. You have been told by a therapist or multiple, by another healthcare provider, by a family member of friend that you could benefit from trying medication for your mood.
  2. You have thought about this decision for weeks, months, or years, with many times being able to talk yourself out of it.
  3. In the past six months there have been changes in your sleep and eating patterns either increasing in sleep and food consumption or decreasing in sleep and food consumption (weight loss or gain).
  4. You don’t feel like yourself. Something’s off. You’re more sad, more irritable, more anxious, more tearful, less motivated, less sexual drive, less able to concentrate, having difficulty at work, and your significant other and/or children notice a change in you.
  5. Hormonal changes can cause increase in depressive and anxiety symptoms- are you menopausal? Are you postpartum? Did you recently stop breast-feeding? Did you start or stop birth control? All of these changes can lead to changes in mood.
  6. Some one in your immediate family with whom you are genetically linked takes anti-depressants and feels a benefit from them.
  7. Season changes cause changes in mood. Is Winter always particularly difficult? Is Spring? Are you having more trouble this year “bouncing back”?
  8. Acute and chronic stress lead to changes in brain chemistry which can lead to depression and anxiety symptoms. Death of a loved one, sudden change in financial situation, divorce, job loss, job stress, traumatic relationships emotionally or physically or sexually. Traumatic childhood abuse over the course of years can lead to depression and anxiety symptoms in adulthood especially if particular memories are triggered.
  9. New diagnosis of a terminal or chronic medical illness can trigger depressive episodes that present with fatigue and pain in addition to other classic depressive symptoms.
  10. Anxiety and panic symptoms can be treated effectively with certain anti-depressants. If you have no depressive symptoms but suffer from high anxiety symptoms, social anxiety, panic symptoms more than three times a week, then you may benefit from an anti-depressant.

All of the above reasons generally impact a person’s level of functioning as an individual, as a spouse, parent, and employee or employer. Not everyone needs medication, but if you are suffering and your life is being impacted do not hesitate to call and seek an assessment. Maybe it’s time to not “power through” but to enjoy the journey.