Man in business wear sits on bench, holding his headAnxiety can manifest in a variety of ways in the human body. It can make us tense in our large, voluntary muscles, activate the involuntary muscles of our internal organs, and even cause changes in our thinking, sensation, and perception. I want to focus here on one particular pattern of anxiety—anxiety in the smooth muscles—and the style of self-punitive thinking that is associated with it.

Smooth muscle anxiety is linked with a wide range of physical problems that are emotional in origin but can be mistaken as medical, which can lead to misspent health care dollars, lost time, and dashed hopes. It is my hope to help you identify manifestations of smooth muscle anxiety, learn about the thoughts linked with smooth muscle anxiety, and gain exposure to intensive short-term dynamic psychotherapy, a model that has demonstrated effectiveness in treating smooth muscle anxiety.

What Are the Smooth Muscles?

The smooth muscle systems of the body include the gastrointestinal system, the vascular system, the bronchi, and the urogenital system. There are also smooth muscles in our skin and eyes. The muscles are called smooth because they are made up of small, mushy, somewhat elastic cells. They differ from our skeletal muscles, which have long, striated fibers that are less flexible.

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When our smooth muscles are functioning as they should, they regulate our blood pressure, digestion, sexual and excretory functions, and breathing—functions that are essential to human survival. However, the smooth muscles are linked to the emotional center of the brain by the nervous system, and they can be activated in response to anxiety (Janig, 2003). So what happens when anxiety impacts the smooth muscles? What symptoms are linked with dysregulation of the smooth muscle systems?

Conditions Linked with Smooth Muscle Activation

The following conditions are associated with involuntary tensing of the different smooth muscle systems (Abbass, 2015):

Are Types of Thoughts Associated with Smooth Muscle Anxiety?

Clinical researchers, especially in the literature on intensive short-term dynamic psychotherapy, have noted an association between self-attacking thoughts and smooth muscle symptoms. While it is not clear whether the self-punitive thoughts can cause a stomachache or migraine, harsh thoughts and smooth muscle symptoms do seem to show up together.

In ISTDP, we use collaborative, exploratory questions to support people as they learn to reflect on the emotions that are making them anxious and triggering self-attack.

Here’s a smattering of thoughts I have heard lately that have shown up alongside smooth muscle symptoms in people I work with:

As these examples from my practice demonstrate, negative thoughts going against the self seem to co-occur with nausea and migraines. If you find that these kinds of thoughts co-occur with your IBS, migraine, or other physical symptoms, or seem to trigger them, you may be experiencing smooth muscle anxiety that has been diagnosed as a medical syndrome.

What Triggers Self-Attack and Smooth Muscle Anxiety?

Clinical research in ISTDP has demonstrated a link between complicated, mixed emotions toward loved ones, tendencies toward self-attacking thinking, and smooth muscle anxiety (Abbass, 2015). The theory of smooth muscle anxiety in ISTDP, which has been repeatedly supported by my experiences as a therapist as well as in case series data (Abbass, 2002) and empirical research (Creed, et al., 2003; Guthrie, et al., 1993), is that mixed emotions toward our attachment figures trigger anxiety. These mixed emotions are anxiety- and guilt-laden because it feels dangerous to have rage toward people whom we long to be close with and depend on.

Because of the anxiety and guilt associated with these feelings, the feelings are repressed—not thought about or reflected on. In fact, self-attacking thoughts seem to have the function of turning the anger toward the loved one back against the self with harsh thoughts and against the body with smooth muscle activation. The beloved person is protected from the anger, and the body and the self are punished. It is almost as though an unconscious, automatic part of the mind says, “How dare you have rage toward your beloved! You must redirect the rage toward yourself and your stomach to protect them!”

The Role of ISTDP in Healing

In ISTDP, we use collaborative, exploratory questions to support people as they learn to reflect on the emotions that are making them anxious and triggering self-attack. Increased reflective awareness of emotions seems to reduce the anxiety connected to them—if it can be thought about, talked about, and felt, it is no longer as scary or guilt-ridden. The complicated emotions we have about our loved ones are no longer unconscious (out of awareness) and frightening but can be seen and felt by the light of day and recognized for what they are—just feelings! People learn that they have been getting punished for emotions, which are mental, bodily events that are not inherently dangerous or wrong. Fear and guilt about emotions are replaced with thoughtfulness, openness, and comfort (Abbass, 2015).

If you are experiencing self-attacking thoughts and smooth muscle anxiety and are looking for systematic support in overcoming the automatic emotional factors that trigger your symptoms, ISTDP may be a useful treatment for you.

References:

  1. Abbass, A. (2002). Office based research in ISTDP: Data from the first 6 years of practice. Ad Hoc Bulletin of Short-term Dynamic Psychotherapy, 6, 5-14.
  2. Abbass, A. (2015). Reaching through resistance: Advanced psychotherapy techniques. Kansas City, MO: Seven Leaves Press.
  3. Creed, F., Fernandes, L., Guthrie, E., Palmer, S. Ratecliffed, J., & Read, N. (2003). The cost-effectiveness of psychotherapy and paroxetine for severe irritable bowel syndrome. Gastroenterology, 124, 303-317
  4. Guthrie, E., Creed, F., Dawson, D., & Tomenson, B. (1993). A randomized controlled trial of psychotherapy in patients with refractory Irritable Bowel Syndrome. British Journal of Psychiatry, 163, 315-321.
  5. Janig, W. (2003). The autonomic nervous system and its coordination by the brain. In Davidson, R. J., Scherer, K. R., & Goldsmith, H. H. (Eds.), Handbook of affective sciences (pp. 135-187). Oxford: Oxford University Press.

Woman takes break from moving and relaxes on sofa with warm drink “When you know better, you do better.” —Maya Angelou

Have you ever met someone who was great at making decisions? Their decisions may not always work out flawlessly, but the confidence they demonstrate when making decisions is impressive. Confident decision-makers have an ability to balance the opinions and advice of others with their inner voice. Even when their plan doesn’t go as hoped, there is a level of peace that comes from knowing, at the time, they made the best decision they knew to make. They learn from the experience and use the newfound knowledge toward their next decision.

So what is the trick to making sound decisions? How can we begin to incorporate this type of confidence when making choices? That depends. There may be research you have to do, people with whom you need to consult, financial situations to consider, time management—the list goes on. What I have found to be one of the most helpful questions to consider during the decision-making process is, “Am I making this decision based on fear or love?”

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What’s love got to do with it? I’m referring to an all-encompassing love for yourself, for others, for the work you do—for your life. Don’t get me wrong; I understand we don’t always have an array of choices we love. Sometimes we have to choose between the lesser of two evils. But when we do, are we basing that decision on fear or love? And why does that even matter?

Think about it. How many times have you made a decision based on fear or reacted in fear and thought, “Gee, that went well! I was at my best when I reacted that way.” A certain level of fear is healthy and keeps us safe, but I’m not referring to physical safety. Our safety and the safety of others is always priority. I’m talking about choices that require us to dig deeper after we’ve done our due diligence, ensured our safety and the safety of others, and examined the logistics. Choices such as:

When we slow down and decide from a place of self-love, we:

  1. Identify and meet our needs in a way that does not harm, manipulate, exploit, or take advantage of others (notice I didn’t say disappoint; sometimes, caring for ourselves first may disappoint others).
  2. Have more clarity about our intentions and expectations, so there is less disappointment if things don’t go the way we hope.
  3. Prioritize our mental, physical, and spiritual well-being, which better equips us to care for and love others.

On the flip side, when fear and anxiety drive our decisions there is a greater chance of regretting them, feeling resentful, and jeopardizing our mental, physical, and spiritual well-being.

Sometimes we may need help from others; a solid support system can help sort through the confusion. Talk therapy can offer a safe, supportive environment for discernment. Finding a good therapist will present you with an opportunity to process your choices and help you develop the skills to manage the emotions that come with them.

Slowing down the decision process will not fully eliminate anxiety or facilitate making difficult choices, but it may allow us to be at peace with our decisions—no matter the outcome.

Remember, take good care of yourself so you can offer the best of yourself to others.

Fresh produce arranged on a wooden table in the shape of a heartAs more mental health practitioners embrace a holistic view of wellness, the role of food and diet is gaining more attention. Numerous studies show a link between healthier diets and lower incidences of depression, anxiety, and other mental health issues.

In their efforts to develop individualized wellness plans, clinicians often work collaboratively with food professionals who can help a person based on their specific needs. Food professionals may include nutritionists, registered dietitians, and others who promote healthy cooking.

If you think your food may be impacting your mood, start with a food assessment and then discuss it with your therapist.

How to Keep a Food Journal

The idea behind keeping record of what you eat is to notice whether there seems to be a correlation between what you’re eating and how you feel.

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Finding a Nutrition Professional to Work with You

Many traditional counseling programs do not educate practitioners about the role of food in mental health. It’s important to do some research on your own and ask your therapist to explore these issues with you. Ask about your therapist’s credentials, training, and experience working with similar cases to yours.

Tell your therapist you’re concerned about your dietary habits, and are looking for a referral to someone who can guide you on nutrition advice. Your therapist may be able to help find someone with a culinary or nutrition degree to provide counsel or classes.

Just as there are different types of mental health professionals, nutritionists, registered dietitians, and chefs generally have different training.

Practical Applications in Dietary Counseling

Many traditional diets or other means of restrictive eating are not healthy or sustainable ways to live. The following are some food takeaways from the so-called Blue Zones, regions of the world where people have the longest lifespan:

  1. Fill your plate with the rainbow: Eating more colors throughout the day generally means you’re consuming an assortment of phytonutrients and antioxidants.
  2. Eat several pieces of fruit per day and aim for 1 pound of vegetables: Higher consumption of fruits and vegetables is associated with a longer lifespan.
  3. Consume more whole grains instead of processed: Whole grains are often affordable and include quinoa, barley, millet, and brown rice.
  4. Eat 1 cup of beans per day: Whether in a bean salad, hummus, or mixed in with rice, research shows that longevity is linked to eating a cup of beans every day.
  5. Limit sugar consumption: If you have a sweet tooth, keep frozen bananas and berries on hand to make smoothies. You can also indulge in medjool dates or dark chocolate.
  6. Keep healthy frozen soups/meals on hand: Families often find it easier to stick to a pattern when they have healthy options on hand. Keep frozen veggies, healthy soups, and pre-made dinners at the ready for busy evenings.
  7. Have plenty of healthy snacks available: These may include apple slices, pretzels, berries, whole grain toast with peanut butter, and fruit smoothies.

Across studies, people’s levels of mental wellness increased with more whole grains, fruits, and vegetables, and fewer processed foods, meats, and dairy items.

Case Examples: Common Mental Health Issues and Food

In the following accounts, names and other identifying information have been changed to protect confidentiality.

Resources to Help Put Healthy Habits into Practice

Diet changes take time to adjust to. Since behavior changes and modifications can be difficult, here are some resources to help you transition to healthier eating habits.

  1. Cooking courses at your local college: Many community colleges and technical schools offer continuing education courses for adults who want to learn healthier eating habits.
  2. Eating support groups: Many people struggle to eat right on a busy schedule. Find or form a Meetup group or other support group online.
  3. Local library: Find both behavioral change and nutrition books that will help you make informed decisions about eating.

Take it one day at a time and attempt to incorporate a new healthy choice each week. In addition to talking to a therapist and any dietary advisers, always consult a medical doctor before making major changes to your diet or if you have a medical condition that requires medication.

References:

  1. Academy of Nutrition and Dietetics. (2016). Nutrition Care Process. Retrieved from http://www.eatrightpro.org/resources/practice/nutrition-care-process
  2. Baranowski, T. (2012). School-based obesity-prevention interventions in low-and middle-income countries: Do they really work? American Journal of Clinical Nutrition, 96, 227-228.
  3. Gregor, M. (2015). How not to die: Discover the Foods Scientifically Proven to Prevent and Reverse Disease. New York, NY: Flat Iron Books.
  4. Jacka, F.N., Kremer, P.J., Berk, M., de Silva-Sanigorski, A.M., Moodie, M., Leslie, E.R., et al. (2011). A Prospective Study of Diet Quality and Mental Health in Adolescents. PLoS ONE 6(9): e24805. doi:10.1371/journal.pone.0024805.
  5. Lally, P., van Jaarsveld, C.H., Potts, H.W., & Wardle, J. (2010). How are habits formed: Modelling habit formation in the real world. European Journal of Social Psychology 6(40), 998-1009.
  6. Murphy, S. (2013). Are You What You Eat? Counseling Today: A Publication of the American Counseling Association. Retrieved from http://ct.counseling.org/2013/02/are-you-what-you-eat/
  7. Natural Gourmet Institute. (2016). Chef Training Program. Retrieved from https://ngihca.edu
  8. Oddy, W. H., Robinson, M., Ambrosini, G.L., O’Sullivan, T.A., et al. (2009). The Association Between Dietary Patterns and Mental Health in Early Adolescence. Preventative Medicine 4(1), 39-44.

Teen hides face in crossed arms on table, binders and books open nearbyGiven that the transition from adolescence into young adulthood is often marked by normal emotional ups and downs, it can be difficult for parents to identify symptoms of mental health issues. Especially after puberty, adolescents experience a variety of changes, both behaviorally and psychologically. They also experience mood swings that can seem severe, depending on the day and the circumstances.

So what should parents be aware of? What should they watch for? Some broad signs that indicate an adolescent’s mood or behavior could be problematic include:

Some of the most common mental health diagnoses among adolescents are depression, anxiety, attention-deficit hyperactivity (ADHD), and eating disorders. Let’s take a closer look at these issues and explore their symptoms.

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Depression

Common symptoms of depression in adolescents are irritability (generally more so than sadness), anger, hostility, and melancholy. Adolescents often have somatic symptoms such as headaches or stomachaches when depressed. Other symptoms to look for are low self-esteem, chronic fatigue, apathy, lack of concentration, emotional dysregulation, and thoughts of suicide. It should be noted that adolescents and young adults can also display symptoms of bipolar, a mood condition similar to depression but with the addition of mania. Mania can manifest as an extreme elated mental state, such as feelings of euphoria, lack of inhibitions, racing thoughts, little to no need for sleep, excessive talking, and risky behavior.

Anxiety

Anxiety can manifest as panic (or panic attacks), posttraumatic stress (PTSD), obsessive compulsion (OCD), social anxiety, or phobias. Parents should take note that PTSD often presents as severe fear of people, places, or things, and can also be diagnosed as phobias, while obsessive compulsion typically manifests as consistent thoughts of an image or impulse. Young adults with anxiety can appear fearful, withdrawn, and emotionally dysregulated.

If you suspect your child or adolescent may have one of the conditions above, it is imperative to seek professional help as soon as possible.

Attention-Deficit Hyperactivity (ADHD)

To identify possible ADHD, parents should also watch for the child or adolescent not being cognizant of their actions, disorganization, a lack of focus, disruptive behavior, and becoming easily bored. The most significant symptom of attention-deficit hyperactivity, in my opinion, is a lack of impulse control. This can manifest as engaging in behavior that seems obviously (to everyone else, anyway) inappropriate. When an adolescent is asked, “Why did you do that?” the answer is often, “I don’t know” or “I wanted to.” In my work with adolescents diagnosed with ADHD, the ability to think through the consequences of a given behavior is often not present. I have worked with adolescents who had ideas that were quite brilliant; people diagnosed with ADHD are often extremely bright and creative. However, when they attempt to execute those ideas, the consequences of not asking permission or crossing boundaries are typically not considered.

Eating Disorders

Eating disorders may include bulimia nervosa, anorexia nervosa, and body dysmorphia. Typically, adolescents with eating disorders aren’t just dieting and exercising to maintain weight. Bulimia is defined as binging and purging to avoid calories being consumed and potential weight gain. Anorexia manifests as eating significantly small amounts of food or no food at all, which can be extremely dangerous or even fatal. Symptoms to watch for are dissatisfaction with the way the adolescent looks, sudden and/or extreme weight loss, going to the bathroom right after eating, fear of weight gain, and a frail or thin appearance.

What to Do If You Suspect Your Child Has a Mental Health Issue

If you suspect your child or adolescent may have one of the conditions above, it is imperative to seek professional help as soon as possible. Depending on the diagnosis and the severity of the issue, treatment may include cognitive behavioral therapy, family systems therapy, and/or medication.

Prompt treatment can prevent a plethora of future problems for adolescents transitioning into adulthood. Adolescents often feel ashamed or embarrassed about their feelings or concerns and thus don’t reveal them. As a parent, that’s where you come in. The fallout for adolescents not receiving appropriate treatment may include low self-esteem, substance abuse, and thoughts of suicide, and can impact various areas of their lives, such as academic performance, work performance, friendships, romantic relationships, and family relationships.

Identifying mental health issues in adolescents can be complicated because it can be hard to delineate potential problems from normal mood and behavioral fluctuations. The key is the severity and duration of the behavior and to what degree it is getting in the way of the adolescent’s ability to function. Behavior that indicates a possible mental health issue is present will typically increase in severity, duration, and disruption in the life of the adolescent over time.

Silhouetted figure runs along beach

Editor’s note: This article is the 15th in an A-Z series on issues related to creative blocks. This month we explore how openness to experience makes space for creativity.

Personality psychologists have identified five dimensions, referred to as the “Big Five,” to roughly describe human personality traits. These dimensions are extroversion, conscientiousness, openness to experience, agreeableness, and neuroticism. In particular, the openness to experience trait is associated with increased creativity and creative achievement. According to personality and creativity researchers, the sensation-seeking drive underlying people with this trait enables them to create more associations between stimuli, to be more self-reflective, and to have a higher interest in acquiring new experiences. As a result, these cognitive and behavioral processes are associated with higher levels of creativity.

So, how can artists and creative individuals use this personality dimension to their advantage in order to maximize creativity? How can being open to experience help one overcome creative blocks? And what if someone is naturally less inclined to exhibit this personality trait?

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Though personality traits tend to be mostly stable throughout one’s lifespan—making it difficult to simply “become” more extroverted or conscientious, for example—our behaviors are more malleable with some focus and persistence. Even if you naturally have more conservative and rigid thinking patterns, you can develop and maintain certain openness-to-experience habits that can maximize potential for creative growth.

  1. Use your imagination: Even if it’s not something that comes up spontaneously for you, you may want to devote 10 to 20 minutes a day to letting your imagination to run wild. This might look something like playing fantasy-based games, brainstorming ideas for short stories, and having a no-filters approach to thinking about future possibilities.
  2. Expose yourself to other artists’ work: One of the characteristics of those who score high on the openness-to-experience measure is the involvement in aesthetically triggering experiences and the appreciation of artistic events. Accepting invitations to art galleries and plays or even going for a walk in nature may stimulate your perceptions and increase your aesthetic sensitivity.
  3. Switch your routine around: It may be comforting to follow a predictable schedule, commute, diet, and after-work routine, but it can limit your sense of receptiveness to new experiences. In order to benefit from the creativity that is correlated with this personality trait, you may want to incorporate an adventurous spirit in your day-to-day life. Adding variety in daily choices may help bring out the openness-to-experience side of your personality.
  4. Engage your intellect and cognitions: A thirst for knowledge and an interest in new information may come more naturally to some than to others. However, a conscious effort to read up on new ideas, pay attention to sensory experiences, learn a new language, and pick up new skills can stimulate the active process of openness to new experiences.

It’s not easy to change basic personality traits. Some might argue it is impossible. However, it is possible to implement behaviors consistent with some personality characteristics, such as openness to experience, especially when they are shown to predict higher creativity.

References:

  1. John, O. P. (1990). The “Big Five” factor taxonomy: Dimensions of personality in the natural language and in questionnaires. In L. Pervin (Ed.), Handbook of personality: Theory and research(pp. 66-100). New York, NY: Guilford Press.
  2. Kaufman, S. B. (2013, November 25). Openness to Experience and Creative Achievement. Scientific American. Retrieved from http://blogs.scientificamerican.com/beautiful-minds/openness-to-experience-and-creative-achievement/

Rear view of a person on swing over the oceanThe term “domestic violence” is an umbrella term that encompasses so much more than just physical violence. It involves a pattern of manipulative behaviors meant to control and maintain power over another individual, and it can happen in any type of relationship. While physical and sexual abuse are the most obvious forms of violence, emotional abuse—often referred to as “invisible wounding”—is something many people encounter, whether in childhood or as an adult, and its effects can be every bit as damaging.

Working in the domestic violence department at a local counseling agency, I frequently encountered individuals who were not sure they “deserved” to be seeking services. Many came in at the urgings of friends or family members, but because they had no bruises, broken bones, or black eyes to show, they timidly questioned whether they were in the right place for the right reasons.

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When I teach tools for building self-esteem, I talk a lot about how we all have a little voice in the back of our heads, feeding us messages all day long. That voice is often referred to as “self-talk” and it plays a huge role in how you feel about yourself; however, as one of my recent workshop participants pointed out, that voice may not always feel like your own. Sometimes the messages we repeat in our own thoughts echo the voices and messages we’ve heard from significant figures in our lives, be it a parent, sibling, teacher, partner, spouse, or other individual.

Over time, the negative, hurtful, or discouraging messages we hear from others get internalized and may cause us to doubt our abilities or value. While some harmful messages are well-intended—for example, a parent focusing on why you got a B instead of an A on a test—others are downright mean, shaming, and belittling. They keep us trapped in a place of self-doubt, holding us back from living up to our full potential.

Eventually, emotional abuse takes a toll on your happiness, self-esteem, and ability to trust in yourself. These consequences of emotional abuse can be just as painful and detrimental as a physical blow.

Bullies and individuals who are abusive or narcissistic may intentionally put you down in their attempts to make themselves feel more powerful. This type of emotional abuse tends to happen so gradually and subtly over time that a victim may not even recognize the behavior as abusive until they are stuck in a seemingly hopeless position. Eventually, emotional abuse takes a toll on your happiness, self-esteem, and ability to trust in yourself. These consequences of emotional abuse can be just as painful and detrimental as a physical blow.

Emotional abuse can wreak havoc on a person’s sense of identity and well-being. It can involve verbal abuse—put-downs and name-calling—and any form of belittling or humiliation. Emotional abuse can also include mind games and attempts to make another person feel guilty or at fault via unwarranted jealousy or something called “gaslighting”—manipulating somebody into doubting themselves.

Emotional abuse may also involve making threats—to leave, take away the children, cause physical harm, cut off financial support, or go through with suicide—and can leave an individual feeling isolated as the abusive person attempts to control who the victim sees and talks to. Coupled with the blaming, denial, and minimization that an abusive person may display, these behaviors can make it extremely hard for somebody in an emotionally abusive situation to maintain the confidence and sense of self-worth that is paramount to leading a healthy and fulfilling life.

Recovering from Emotional Abuse

The damage from emotional abuse can be profound and the scars run deep; however, it is possible to take back control of your life. Doing so takes courage and determination. It involves beginning to believe in your worth and starting to let go of the disparaging commentary you’ve incorporated into your inner dialogue. As you gain self-acceptance, you may be better able to stand up for yourself, be assertive, and set healthy boundaries.

If you have been affected by emotional abuse, I encourage you to seek help from an experienced therapist to work through the lingering hurt and trauma as you reclaim your voice. Be advised that while the long-term benefits of standing up to emotional abuse are worthwhile, the short-term setbacks may seem insurmountable. Because an abusive person typically seeks to maintain power and control, your attempts to begin standing up for yourself may be met with resistance and an even greater attempt to break your spirit down. But don’t let this hold you back.

Imagine a balancing scale: As you become healthier and begin standing up for yourself you gain back some control, evening the scale and causing the abusive person to lose some sense of power. The abusive person may increase the attempts to control you in order to raise their end of the scale back up and push your end farther down.

Be aware that these attempts may result in an escalation of abusive behaviors. Where there is emotional abuse, there is an increased risk of potential physical violence, so if you feel unsafe it is especially important to get support in your journey to heal and become empowered. As you learn methods to stay safe and increase self-esteem, you can begin to renounce the negative messages thrown your way and instead acquire your own voice of self-acceptance. With time and effort, you will be able to maintain your position in that balancing scale, sending the message that you will not tolerate being emotionally abused.

Person in black sits against fence with sad expression“To spare oneself from grief at all cost can be achieved only at the price of total detachment, which excludes the ability to experience happiness.” —Erich Fromm

We all know breakups are hard. Every one of us has experienced some form of heartache at one point or another, but we all experience and are affected by it in different ways. Why do some of us come out stronger in the end while others end up feeling beaten down and defeated? How can we harness the potential healing power of pain?

Fortunately, with enough will and hard work, this is a skill that can be learned by almost anyone.

Any breakup, even in the shortest-lived of relationships, can hurt like hell. One of the most devastating losses one can face, aside from the loss of a loved one, is the loss of potential—what could have been. The beginnings of any relationship carry with them the seeds of unlimited hope and potential. More often than not when a relationship doesn’t work out, it is not necessarily the person we ache for, but rather the story we created around them: what the person could have brought to our life, the vision we had for ourselves, and how the person fit into that vision.

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Breakup: Where Crisis Meets Opportunity

Like any crisis, a breakup can be an opportunity. In his book You Can Heal Your Heart: Finding Peace After a Breakup, Divorce, or Death, David Kessler describes loss as a window into old wounds. The end of any romantic relationship, be it a 20-year marriage or a three-month fling, can trigger a number of unconscious memories and hurts we thought had long ago healed. Much in the same way a familiar scent can take us back to a long-forgotten time or place, the pain of a breakup can open the deepest of wounds.

This could be just what we need to compel us to take a good look at our patterns and begin to change them. Breakups can be opportunities to reclaim our lives, on our terms, and to change any distorted thinking we may have around love and relationships. For example, metaphorically speaking, do you tend to date the same person over and over again, or do you find yourself dating the parent who loved you the least? Do you tend to idealize your partners? This could be a chance to learn how to see through the initial fog of infatuation, let go of unrealistic ideals, and move toward the relationship that is right for you.

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How to Cope with the Pain of Breakup

Kessler reminds us that if there is grief, there was love. What a beautiful thing to have been able to love and be loved! Though many would maintain it is better to have loved and lost than to have never loved at all, some may prefer to avoid potential heartache by never risking loss. This may be a way to avoid the temporary pain of breakup, but it’s also a surefire way to miss out on one of the greatest joys of life.

Keeping the positive front and center in the devastating aftermath of a breakup is no easy task, though. So what to do? How to cope? The following are a few ideas and reminders:

  1. Give yourself permission to mourn. You don’t heal if you don’t feel! Perhaps the most unproductive thing you can do with your emotions is shut them off. Whether five years or five months, a broken attachment hurts. The length of time or circumstances don’t matter so much as what these wounds stir up unconsciously. We all carry some baggage, but if you don’t allow yourself time to go through the stages of grief, you may run the risk of taking unresolved anger and resentment into your next relationship.
  2. Reach out to your “fan club.” Surround yourself with positive supports. This is especially important if you were with someone who was emotionally or otherwise abusive. Spend time with friends, family, mentors, and others who can reflect back to you the wonderful, valuable, lovable person you are.
  3. Talk to a helping professional. As a therapist, I may be biased, but if you’re not already in therapy you may want to consider it—especially if you recognize destructive patterns in your relationships. Working with a therapist, whether individually or in a group setting, is a great way to learn about and begin to change unhealthy relational patterns.
  4. Find the lesson meant for you. As Kessler notes, breakups can be opportunities to learn about yourself and grow. Learning a “lesson” doesn’t mean you did something wrong. It means taking ownership of your happiness and taking advantage of a chance to create stronger relationships and possibly heal hurtful memories and distorted beliefs.
  5. Channel your creativity. If you haven’t already done so, try to identify a creative outlet or activity that speaks to you and helps you heal. This can be journaling, painting, or taking an improv class, for example. As a writer and a former actor, I can attest to the cathartic power of creative pursuits.
  6. Get back out there. There is something to be said for so-called “rebound” relationships—so long as all involved are honest with each another about what they’re looking for and how long they’re looking for it. Only you can determine when you are ready to re-enter the dating world. Whether for the purpose of finding a long-term relationship or simply to broaden your social circle, meeting people and cultivating new friendships, romantic or otherwise, can nourish the soul and help you develop a support network. So even if your next date doesn’t turn out to be the one, they could turn out to be a new best friend!

Of course, all of this is substantially easier said than done. As I write this, I’m reeling from my own recent breakup. It is what compelled me to write this piece, as writing is one of my creative healing outlets. My hope is to remain faithful to the advice I offer above. I will allow myself to grieve as I look for the lessons meant for me. And during the most difficult moments, I will remind myself that where there is grief, there was once love.

References:

  1. Hay, L., & Kessler, D. (2015). You can heal your heart: Finding peace after a breakup, divorce, or death. Carlsbad, CA: Hay House, Inc.
  2. Kübler-Ross, E., & Kessler, D. (2005). On grief and grieving: Finding the meaning of grief through the five stages of loss. New York, NY: Scribner.

Person in white lab coat sits on swing looking thoughtfulWhich is worse: that sinking feeling in the pit of your stomach after that person you just had a promising first date with says they don’t see it going further, or receiving a call from a recruiter who tells you the company you desperately want to work for has decided to hire someone else?

They are both forms of rejection—decisions by others to not go forward with a relationship you hoped to have. Do you like your rejection as a gentle letdown or as a quick blow? In one scenario, you are left to figure out why you aren’t wanted. In the other, you are told why. And in both, you are left to wonder what other potential suitors have that you don’t. When we are rejected, we tend to revisit the things we said and did, reimagining situations where we might come out on top.

Even if we didn’t want the date or the job, we still want some control, perhaps the opportunity to say, “Thanks, but no thanks.” We want the power to do the rejecting. We will do almost anything to avoid that helpless feeling that comes when someone takes the decision away from us. This feeling often overtakes the truths we know about ourselves.

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The logical part of the brain knows we aren’t everyone’s cup of tea. We know there will be those who are better suited for certain jobs. The people I meet in therapy often laugh when we discuss this idea, because what we must believe in when we let rejection get to us is actually quite silly. However, rejection has hidden benefits lurking beneath those burning feelings of disappointment, anger, embarrassment, humiliation, and self-criticism. One is the opportunity to practice resilience. In dealing with rejection, we get a chance to seek a better fit for ourselves and trust that the relationship or situation we wanted wasn’t right and a better one is still out there. If we get invested in dating someone who isn’t as invested in us or in doing a job that doesn’t value our skills, we aren’t investing in more fulfilling or rewarding people and situations.

One of the most difficult feelings that often comes with rejection is embarrassment. By feeling embarrassed when we fall short of a goal, we convey to others a sense of, “I’m not good enough, and now everyone can see that.” Rejection is a part of life that everyone experiences in one fashion or another, so to feel embarrassment is to believe in the illusion we are universally wanted and should be seen by others as such. That’s neither realistic nor fair.

Rejection has hidden benefits lurking beneath those burning feelings of disappointment, anger, embarrassment, humiliation, and self-criticism. One is the opportunity to practice resilience.

It is especially problematic when an experience of rejection snowballs and affects your self-worth. It can be exhausting to go out on the job market or dating scene and endure countless interviews and meet-ups that don’t lead to what you want. Often I see people in my office who need to be reminded of their worth and to consider a different approach to looking for a job or partner. Many people interpret meaning and patterns from their experiences. For example, they may decide they should never talk about enjoying time with their baby nephew because it “scares away” potential dates who might not be ready for kids. Or they conclude they don’t have the problem-solving skills it takes for the kind of job they want after a phone screening doesn’t net an in-person interview.

It is easy and tempting to invent reasons we don’t get what we want, but therapy can help sort through what is real and what is not.

The next time you encounter rejection, keep in mind the following ideas:

Female doctor treats a man with depression.According to a recent health story from National Public Radio, depression is the catalyst for more than 8 million doctors’ appointments each year. More than half of those appointments are with primary care physicians, which highlights the important role primary care physicians have in the screening, diagnosis, and treatment of depression and other common mental health conditions.

Despite the high number of individuals trying to access some level of mental health treatment through their primary care physicians’ offices, a 2013 brief by the Centers for Medicare and Medicaid Services (CMS) estimates 80% of adults experiencing mental health issues never see or are referred to a mental health specialist for treatment. In fact, CMS suggests that only 25% of people with depression or other common mental health issues ever receive effective care.

[fat_widget_right]To address the significant gap that exists between mental and physical health treatments in primary care settings, CMS has pushed for states to adopt a collaborative care model that integrates primary care with case managers and mental health specialists. This approach mirrors the treatment guidelines from the American Psychiatric Association, which advocates for treating major depression, from mild to severe cases with psychotic features, with a combination of pharmacotherapy and psychotherapy.

As a leading online directory of psychotherapists, psychiatrists, and mental health specialists that has helped connect millions of people with a mental health professionals since 2007, GoodTherapy.org recognizes the importance of collaborative care. Below, we outline three powerful reasons for physicians to refer to or collaborate with mental health specialists:

Mental Health Referrals and Collaborative Care Help Provide Better Treatment for Your Patients

The Centers for Medicare and Medicaid Services estimate that as few as 20% of people who started an antidepressant medication in primary care will show “substantial clinical improvement.” Additionally, CMS states that we know when mental and behavioral health concerns are left untreated, the following occurs:

Despite the high level at which patients enter primary care for depression and other common mental health issues, a recent study published in the journal Health Affairs suggests that primary care practices may not be well equipped to manage depression as a chronic illness. Simply put, reaching out to a mental health professional for collaborative care may allow you to provide better mental and physical health outcomes overall for your patients.

Available Evidence Supports the Efficacy of Collaborative Care for Mental Health Issues

The collaborative care approach has been studied extensively across various primary care settings and populations. In its brief on collaborative care, CMS points to more than 70 randomized controlled trials as its body of evidence for The gaps in mental health treatment exacerbate poor physical health for many and causes some to live with treatable mental health issues, often as a result of stigma. Pursuing better approaches to treating mental health and wellness creates a world of stronger, healthier communities, which benefits us all.the treatment model. The agency found that collaborative health care teams consisting of a primary care provider, support care management staff (such as a psychologist or clinical social worker), and a psychiatric consultant were both more effective at delivering better health care outcomes and more cost-effective overall, regardless of practice size or population being treated. Additionally, several studies highlighted by CMS indicate a collaborative approach to health care may be especially effective at reducing health disparities in ethnic minority groups and low-income populations.

The IMPACT Trial, a program of the University of Washington Department of Psychiatry and Behavioral Sciences, is one of the largest research projects to have studied depression care. The study followed the outcomes of more than 1,800 adults experiencing depression from more than 18 different primary care facilities over a 2-year period.

According to the findings of the IMPACT Trial, published in 2002 in the Journal of the American Medical Association, people experiencing depression who received collaborative care reported a 50% reduction in symptoms, compared to about 19% who received care from a physician only. Additionally, follow-up research after the conclusion of the IMPACT Trial revealed that patients who received collaborative care experienced more than 100 additional days free of depression symptoms over a 2-year period when compared to those treated solely by a primary care physician.

Reaching Out to Mental Health Partners Makes Physical and Mental Health Care More Cost-Effective

Referring a patient to a mental health specialist or integrating mental health care as part of a collaborative care approach makes financial sense too. The Centers for Medicaid and Medicare Services estimate that health care costs can increase by 50-100% if a patient is experiencing depression. Additionally, patients experiencing major depression and a chronic medical condition, on average, have more than twice the health care costs when compared to people who aren’t experiencing depression.

Another important part of the University of Washington’s IMPACT Trial was examining long-term health care costs over a 4-year period. At the end of the study, researchers discovered an initial investment in collaborative care resulted in significant savings over time. The published results indicate that every dollar spent on collaborative care saves $6.50 in health care costs. Primary care practices that used a collaborative care approach for depression treatment during the study saved an average of nearly $850 per year for each patient. The average net cost savings over a 4-year period for people with depression were about $3,400 per patient.

How We Can Help

Part of our mission at GoodTherapy.org is to challenge mental health stigma and educate the public about mental health conditions and treatment. The gaps in mental health treatment exacerbate poor physical health for many and causes some to live with treatable mental health issues, often as a result of stigma. Pursuing better approaches to treating mental health and wellness creates a world of stronger, healthier communities, which benefits us all.

Our organization is ranked as one of the top directories of mental health professionals, therapists, and psychiatrists on the internet, with thousands of members in more than 30 countries worldwide. Visitors to GoodTherapy.org can search for a mental health specialist or therapist by location, specialty, treatment modality, or several other factors. We ensure the highest membership standards of any online mental health directory and verify that each member meets strict educational, licensure, and philosophical guidelines.

Whether you’re searching for a mental health referral or a partner to assist your practice in a collaborative care approach, GoodTherapy.org can help you provide better, more cost-effective treatment for people experiencing mental health challenges.

References:

  1. Bishop, T. F., Ramsay, P. P., Casalino, L. P., Bao, B., Pincus, H. A., & Shortell, S. M. (2016 March). Care management processes used less often for depression than for other chronic conditions in US primary care practices. Health Affairs, 35(3). 394-400. doi: 1377/hlthaff.2015.1068
  2. Luthra, S. (2016, March 7). Doctors often fail to treat depression like a chronic illness. NPR. Retrieved from http://www.npr.org/sections/health-shots/2016/03/07/469504900/doctors-often-fail-to-treat-depression-like-a-chronic-illness
  3. Overview of the IMPACT trial. (n.d.) University of Washington, Department of Psychiatry and Behavioral Sciences. Retrieved from http://impact-uw.org/about/
  4. Treating major depressive disorder: a quick reference guide. (n.d.) American Psychiatric Association. Retrieved from http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd-guide.pdf
  5. Unützer, J., Harbin, H., Shoenbaum, M., & Druss, B. (2013 May). The collaborative care model: an approach for integrating physical and mental health care in medicaid health homes. Health Home. Retrieved from https://www.medicaid.gov/State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical-Assistance/Downloads/HH-IRC-Collaborative-5-13.pdf

A woman dries dishes while teen friends talkFriendship—that close connection with another person which allows us to feel valued and cared for—is vital at any stage of life. The need for love and belonging has long been established as one of our basic needs as human beings. And it has been well documented that having strong, healthy relationships improves our self-esteem and overall well-being. As valuable as these connections are, however, they do not always come easily or naturally, particularly for adolescents.

We’ve all known the charismatic, outgoing teenager who is friends with everyone and approaches social situations with ease and grace. We’ve also known the awkward, insecure teenager who struggles to connect with people and becomes more withdrawn with each friendship that crashes and burns. While some of it has to do with personality and development, it is just as important to remember that just like so many aspects of adolescent development, making friends is a skill that can be learned.

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If it seems like it was easier for your child to make friends when they were young, you’re right. When kids are little, most of their friendships are cultivated and managed by adults. Parents set up “play dates,” organize the activities, and manage any conflict that pops up. Parents also plan birthdays and other parties, and manage the invitations, gifts, and RSVPs to make sure everyone is included.

The good news is making friends boils down to a series of skills that can be learned.

As kids become teens, these friendships start to shift and evolve. As is true with so many things about middle school, teens become more independent and start making choices for themselves, so it makes sense they also become more independent in managing their friendships. Some kids handle this transition effortlessly, while others struggle mightily with making and keeping friends. And those friendship struggles can lead to a lack of confidence and feeling disconnected and vulnerable at a crucial time in their development.

The good news is making friends boils down to a series of skills that can be learned. And as with any new skill, becoming proficient at friendship requires some self-awareness, some guidance, and practice. Here are some tips for helping your teen improve their friendship skills:

  1. Invite your teen to do some reflecting. Ask them, “What qualities do you have that would make people want to be your friend?” And more importantly, “How do people know that about you? How do you let people see what you value, what’s important to you, and who you really are?” Rather than just looking around for someone with common interests, helping teens become clear about who they are and what they value allows them to attract friends who will be a good fit for them.
  2. Remind your teen that not every acquaintance will become a BFF. Teens who struggle with making friends tend to latch onto the first person who shows them meaningful attention. They may share too much personal information too soon, and they may become jealous and insecure when their new best friend has other friends. Help your teen work through the difference between a friend you sit next to in class and chit-chat with, and a friend who really understands and values you.
  3. Teach your teen how to engage in conversation. Small talk is a learned skill. It doesn’t come easily for everyone. It is particularly difficult for teens who are more introverted. Practice having light, casual conversations about easy topics such as music, activities outside of school, or homework. Help them learn how to keep it positive, and promote the value of listening more than they speak.
  4. Help your teen understand that conflict is a natural part of relationships. Even the best of friends are going to have fights, but not every argument means the end of a friendship. Help them work on fighting fair and knowing when to take a break from an argument to cool off. Particularly when it comes to social media, where misunderstandings are common and conflict can quickly get out of control, teach your teen the value of saying, “I think we’re both really upset. Let’s talk about this in person tomorrow.”
  5. Be aware of your own judgments and opinions. If you don’t like your teen’s new friend and you believe your reasons are valid, be thoughtful about how you bring it up. Opening a conversation with, “Tell me what you like about hanging out with her” may be much better received than the more obvious, “I don’t like her! She’s a brat!” And if you feel the need to criticize your teen’s friend, be sure to be specific about the behaviors you don’t like. For example, “I’ve noticed she cancels plans with you at the last minute a lot” opens up a much healthier conversation than, “I don’t like her. She’s so selfish and disrespectful!” Your teen values your opinion much more than they will ever let you know, so if you notice them being treated badly by a friend, by all means speak up. Just make sure you do it in a way that is likely to be heard.
  6. Help your teen foster other relationships. The need for connection and belonging extends beyond friendships with peers. Make sure your teen feels connected to you and other adults in their life. When teens have solid, healthy relationships in their lives that they can count on unconditionally, it becomes much easier to endure the roller coaster of adolescent friendships.

Friendships during the teen years can be so important and fulfilling. Having someone to lean on, share secrets with, and let loose with makes life better at any age. If your teen is struggling with friendships, remember that it is not a lost cause. Make sure your connection with them is strong, and guide them toward the skills they need to make the kinds of friends that will serve them well.

References:

  1. Mayo Clinic Staff. (2014, February 5). Friendships: Enrich your life and improve your health. Retrieved from http://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/friendships/art-20044860
  2. Substance Abuse and Mental Health Services Administration (SAMHSA). (2002). Making and keeping friends: A self-help guide. Retrieved from http://store.samhsa.gov/product/Making-and-Keeping-Friends-A-Self-Help-Guide/SMA-3716

Rear view of two women looking out over a lakeDespite some recent legal changes to protect the civil rights of LGBTQ+ people in some states, we continue to be the most common targets of hate crimes in the U.S. (Park and Mykhyalyshyn, 2016). No such crime has resonated in the public consciousness like the one that took place in the early hours of June 12, 2016 at a gay nightclub in Orlando, Florida, where 49 people were killed and 50 others injured by a lone gunman in “the deadliest attack on the LGBT community in U.S. history” (Ravitz, 2016).

The incident created a ripple effect of grief, fear, anger, and unity among those directly and indirectly affected by it. Through the bonds of shared trials and tribulations that come with being a marginalized group, the LGBTQ+ community provides vital safety and connection—a “family of choice,” if you will—for those who may not be accepted even within their families of origin. Because this connection is so deeply rooted, it only makes sense that the Orlando tragedy devastated and traumatized the whole of our community.

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Research has demonstrated that acts of terrorism erode “the sense of security and safety people usually feel” (Hamblen and Sloane, 2016). But what about people who weren’t accustomed to feeling safety and security in the first place? Even those of us in the LGBTQ+ community who have been able to legally marry our partners face conscious and unconscious threats and concerns on a daily basis: disclosing LGBTQ+ identity to coworkers/employers, choosing certain clothing options to avoid detection of our identity, researching how our community is treated in a given location before planning a trip, making split-second calculations as to whether it is safe to show even minimal forms of public affection. It is our complex set of collective experiences that places us at risk for having our previous experiences of aggression and microaggression triggered by an act of violence like the one in Orlando.

Guarding Against Secondary Trauma

Those of us in the helping professions have been trained to guard ourselves against vicarious trauma. This type of secondary trauma is the “emotional residue of exposure that counselors have from working with people as they are hearing their trauma stories and become witnesses to the pain, fear, and terror that trauma survivors have endured” (American Counseling Association, 2011). However, secondary trauma is a concern for anyone, not just mental health professionals. According to a 2015 study, individuals viewing traumatic events through various forms of media are susceptible to trauma-related symptoms despite having no direct connection or experience of the traumatic event (British Psychological Society, 2015).

So what can we do to cope in the aftermath of Orlando? First, it’s a good idea to check in with loved ones and ourselves and notice if there have been changes to daily routines (such as eating and sleeping) and functioning (concentration, racing thoughts or worries, increased startle responses, etc.). If there have been changes, the U.S. Department of Veterans Affairs (2015) recommends the following self-care approaches:

We can also borrow from the tips given to professional helpers to transform trauma into something positive. The Headington Institute, specializing in helping humanitarian workers cope with the traumas they witness, has several tips for achieving this transformation (Ashimoto, 2014):

As a therapist and a member of the LGBTQ+ community, I challenge my “family of choice” and our allies to transform this trauma, even as we mourn.

References:

  1. American Counseling Association. (2011). Fact Sheet #9: Vicarious Trauma. Retrieved from http://www.counseling.org/docs/trauma-disaster/fact-sheet-9—vicarious-pdf?sfvrsn=2
  2. Ashimoto, F. (2014, October, 6). Transforming vicarious trauma [Video file]. Retrieved from http://www.headington-institute.org/blog-home/433/transforming-vicarious-trauma
  3. British Psychological Society. (2015, May 6). Viewing violent news on social media can cause trauma. ScienceDaily. Retrieved from http://www.sciencedaily.com/releases/2015/05/150506164240.htm
  4. Hamblen, J., & Sloane, L. (2016, February, 23). Research findings on the traumatic stress effects of terrorism. Retrieved from http://www.ptsd.va.gov/professional/trauma/disaster-terrorism/research-findings-traumatic-stress-terrorism.asp
  5. Park, H., & Mykhyalyshyn, I. (2016, June, 16). G.B.T. people are more likely to be targets of hate crimes than any other group. Retrieved from http://www.nytimes.com/interactive/2016/06/16/us/hate-crimes-against-lgbt.html?_r=1
  6. Ravitz, J. (2016, June, 17). Before Orlando: the (former) deadliest LGBT attack in US history. Retrieved from http://www.cnn.com/2016/06/16/health/1973-new-orleans-gay-bar-arson-attack/
  7. U.S. Department of Veterans Affairs. (2015, August, 14). Coping with traumatic stress reactions. Retrieved from http://www.ptsd.va.gov/public/treatment/cope/coping-traumatic-stress.asp

Waist down view of a woman having a dress alteredEditor’s note: This article is meant to provide information about gender transition and why a transgender person may choose to transition. It does not attempt to speak for trans people. We recognize everyone has a different experience, and we welcome you to share yours in the comment section below.

“So, when are you getting surgery?”

“Are you taking hormones yet?”

“Why would you want to go to all that trouble?”

These are just a few of the questions people in the process of coming out as transgender might face. Friends and family members who may have little to no understanding of gender transition or of what it means to be trans may ask invasive questions, make inappropriate inquiries, or say things that are invalidating or hurtful, regardless of intention.

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Transition—the process by which an individual begins to live as a member of another gender—can be complex. It may involve many steps for some and fewer for others. These steps might include changes to legal documents, gender confirmation surgery, alterations to physical appearance, name and pronoun changes, and hormone replacement therapy, among others.

A person’s reason for choosing to transition, and the goals they have regarding transition, are personal and unique. Some individuals may not pursue certain aspects of transition, whether through personal choice, lack of resources, or lack of access. There is no single “right” way to transition. A person’s gender identity does not depend on whether they have had surgery or if they are taking hormones.

Why Do People Transition?

A person might realize they are trans (that their gender identity does not align with their birth sex designation) at any point in life. Some people may first experience an internal sense of identity that does not match their external characteristics in early childhood. Others report realizing this in puberty or later. Societal gender norms and expectations may contribute to a person’s realization of their true gender identity. These assumptions can also contribute to dysphoria, as a person might first attempt to conform to societal expectations by expressing a gender identity they do not have.

Gender dysphoria, which is believed to result from a mismatch between the brain’s internal map of the body and the actual physical body, is experienced by many trans people. The feelings of distress frequently associated with this condition may have a negative impact on a person’s quality of life.

Transition, whether social, through hormone therapy, through surgery, or through some combination, often improves feelings of dysphoria, though it may not relieve them completely. The goal of many is for their gender to be perceived correctly by others, which is often referred to as “passing.” Typically, people transition to align their physical appearance and characteristics with their gender identity. Many people begin the process after years of dysphoria and distress, and transitioning may help them feel as if they are finally able to be their true selves.

Understanding Transition

Family members and friends may find a person’s true gender difficult to accept. “You’ll always be ____ to me,” a mother might say, without the intention of harm. But this type of remark may be invalidating and cause distress in individuals who no more chose their gender identity than they chose to be born with blue eyes or brown hair. Participating in therapy or counseling sessions can help family members accept a person’s gender identity. In counseling, they may be able to ask questions, come to a better understanding of what it means to be transgender, and learn more about what transition entails.

According to Kimber Shelton, PhD, a licensed psychologist in Duncanville, Texas, transitioning can have significant psychological, social, and physical benefits: “In my experience, individuals who transition express that the desired effects of hormones and surgery outweigh the potential risks (such as increased acne or balding from hormone replacement therapy).”

Anxiety and depression caused by gender dysphoria may diminish as dysphoria improves. Individuals who no longer have to make uncomfortable adjustments—such as hiding unwanted physical characteristics—may not only feel better physically but may have greater confidence and self-esteem, Shelton also said.

Social Transition

People generally begin the transition process on their own before seeing a therapist or doctor. Even if a person has decided on medical transition, it may not be possible to begin immediately. Social transition is the first step for many, and some people may transition only socially.

Socially transitioning means a person makes changes in appearance and social situations to reflect their gender. This may include changes to hairstyle and clothing, name and pronoun changes, and use of different bathrooms/gendered facilities. When a trans person first comes out as trans, they often share their correct pronouns and their chosen name. They might share this widely—at home, school, or work—or they might disclose these changes only to family and close friends. Using the correct pronouns and the name a person has chosen shows support and acceptance of that person’s identity, but using an incorrect name and pronouns, beyond invalidating that person, could place them in danger or subject them to discrimination, harassment, or abuse in some situations.

Legal Transition

The legal process of gender transition typically requires several steps, and in America, the process varies widely between states. All states allow name changes, but birth certificates issued in the states of Idaho, Kansas, Ohio, and Tennessee cannot currently be changed. This restriction can prevent trans people who desire to change their gender marker from being able to fully transition. Many trans people do not wish to disclose the fact they are trans, but being unable to change their gender marker may force them to do so and can prevent them from changing other documents.

Seeking education about the issues and concerns trans people face and offering acceptance and support can be of great benefit not only to a trans friend or family member but to the trans community.

Some states or individual treatment agencies require the completion of certain aspects of transition before providing others. For example, several states require gender confirmation surgery before issuing a birth certificate bearing the correct gender marker. Because this surgery is expensive and often not covered by insurance, it may be out of reach for some  who desire it. Individuals who choose to transition without surgery but want their legal documents to reflect the correct gender may also be prevented from achieving this goal.

Steps for legal transition might include:

Hormone Therapy

Some people choose to take hormones as part of their transition process. Hormone therapy, which helps people develop secondary physical characteristics that reflect their true gender, can greatly impact those who are transitioning. People who choose to take hormones may see changes right away, but it can take years before the changes are complete. Some changes are not reversible, but others are, and hormone therapy will typically continue for the rest of a person’s life, unless that person chooses to stop taking hormones. The effects of hormones may vary, and changes cannot be predicted or controlled. They may take effect more quickly in some individuals than in others.

In most states, individuals seeking hormone therapy need a letter from a mental health professional confirming the presence of gender dysphoria and recommending hormone therapy to treat it.

Male to Female (MtF) Hormone Therapy

People assigned male at birth who choose to take hormones will generally take estrogen and anti-androgens, also known as androgen blockers. Estrogen both feminizes features and helps to suppress testosterone, while anti-androgens block the effects of testosterone. Effects may include:

MtF hormone therapy does not have an effect on beard hair or voice. Voice therapy can help women reach the desired pitch and modulation, while laser hair removal and other treatments may be necessary for lasting facial hair removal.

Female to Male (FtM) Hormone Therapy

Testosterone is taken people who were assigned female at birth. Effects of testosterone may include: A young adult sits in apartment looking through box of records

Testosterone does not cause breast size to decrease, though the redistribution of body fat may make them less firm, and it cannot change the size of a person’s hands or feet. Anecdotal evidence suggests some men may experience a small growth spurt, but a slight increase in height might also be attributed to change in posture.

Nonbinary Hormone Therapy

Society has traditionally adhered to a gender binary that recognizes male and female identities. Many trans people do transition from female to male or male to female, but those who have a nonbinary, genderqueer, or other identity may also transition (though some nonbinary people do not identify as transgender). Though in the past the Standards of Care for the Health of Transexual, Transgender, and Gender-Nonconforming People reflected a gender binary rather than a wider spectrum of gender, the current edition uses language reflecting the acceptance of nonbinary and genderqueer people.

Though society is beginning to recognize and accept the existence of nonbinary identities, some people may find it difficult to accept other genders or understand why nonbinary individuals want to transition. It may be helpful to remember nonbinary individuals are no less transgender than those who have a gender that may be more familiar. They can still experience dysphoria, be misgendered, and desire to pass in society as a member of their gender, and hormone therapy can benefit them in the same way it benefits other trans people.

Hormone Therapy for Adolescents

Some youth may know they are transgender and want to begin transition, but their parents or doctors may want them to wait until they are more “certain” of their gender identity. However, waiting can be harmful, as changes that occur in puberty may induce dysphoria, which can have an effect on mental health. Trans teens often experience high levels of depression and substance abuse and have a high risk of suicide. Those who are able to transition typically report significant improvements in mental health and emotional well-being.

Health care professionals often prescribe puberty blockers, which delay the development of physical characteristics associated with sex assigned at birth, to trans youth until they are considered old enough to begin hormones. Some researchers suggest waiting until age 16, as the effects of hormone therapy on developing bodies are not entirely known.

Gender Confirmation Surgery (GCS)

Previously known as gender reassignment surgery or sex reassignment surgery, GCS alters a person’s genitalia and/or chest in order to reflect their gender. Calling these procedures “gender confirmation surgery” may help reinforce the fact gender identity is not a choice.

Young person in yellow coat smiling on college campusIn the past, GCS was typically considered cosmetic, and trans people could expect little to no help from insurance companies. Today, many of these surgeries are known to be medically necessary for trans people, as aligning the physical body with internal identity can greatly relieve distress, mental health symptoms, and suicidality. All major psychological, psychiatric, and medical organizations in the U.S. have made statements to this effect, and many insurance companies now cover some GCS procedures, including mastectomy, gonadectomy, and genital reconstructive surgery.

Surgery to alter facial features, contour the body, modify the voice, increase breast size, or change nose shape or size may assist in the masculinization or feminization of physical characteristics. However, most insurance companies still consider these procedures cosmetic.

To receive gender confirmation surgery, individuals typically need to provide one or two letters of referral from a qualified mental health professional. Some providers require the individual to have had hormone therapy and lived as their gender for a period of time before receiving surgery (though this requirement may be waived in some cases).

Adults who do not have sufficient insurance may have to pay for medical procedures out-of-pocket, which may not be feasible for some. Shelton points out the ability to transition through surgery or hormone therapy is a privilege not everyone has. Some trans people do not have access to any health care resources at all and are unable to pursue any type of medical transition.

How to Offer Support

Some people believe trans people are confused, that they want to transition to be “different,” or that the surgery and hormones they need are nonessential. However, research has shown transgender people are not confused; hormone therapy and GCS can greatly increase quality of life; and the potential risks of hormone therapy and surgery are often far outweighed by the positive effects of transition. Seeking education about the issues and concerns trans people face and offering acceptance and support can be of great benefit not only to a trans friend or family member but to the trans community as a whole.

Immediately referring to a person by the correct pronouns and their chosen name, when that person has shared that information, is one way to show support. If a mistake is made with a person’s name or pronouns, apologizing, correcting the mistake, and moving on is often the best way to handle it.

Avoiding questions that could be considered invasive is also a way to show support. Being expected to provide information about “all things trans” can place the burden of being an educator on people who may not want or be able to take on this role and may lead to them experiencing emotional distress. This expectation may also be colored with the assumption that every trans person will take the same approach toward transition.

Some people may willingly discuss their transition, but it is important to respect their boundaries by allowing them to begin the conversation, direct it, and end it when they no longer feel comfortable.

Simply offering acceptance can be a significant mark of support, and doing so is likely to help an individual transition with greater ease.

References:
  1. American Counseling Association. (2010). American Counseling Association Competencies for Counseling with Transgender Clients. Journal of LGBT Issues in Counseling, 4(3), 135-159.
  2. American Psychological Association. (2015). Psychological practice guidelines with transgender and gender nonconforming clients. American Psychologist, 70(9), 832-864.
  3. Ashbee, O., & Goldberg, J. M. (2006). Hormones: A guide for MTFs. Vancouver: Canadian Rainbow Health Coalition and Vancouver Coastal Health.
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