Activism and Clinical Social Work
I wrote the following article for the Pennsylvania Society of Clinical Social Work’s Winter 2011 newsletter:
Clinical Voice
PSCSW Newsletter
Winter 2011
Activism and Clinical Social Work
I entered the field of clinical social work with the goal of filling a gap in services in my community. I wanted to provide inclusive and empowering psychotherapy to lesbian, gay, bisexual, transgender and queer (LGBTQ) adults and adolescents; not because I think all queer folks need therapy – but because I feel that anyone who wants to access counseling should be able to without fear of rejection or discrimination. Early this fall, the mainstream media drew attention to several gay male adolescents who took their own lives. Media coverage activated many responses to these tragedies. As a queer person and a clinical social worker I found myself reflecting on the intersections between advocacy, education and clinical social work and how those intersections impacted me and my clients.
The most heavily reported suicide was the death of Tyler Clementi, a freshman at Rutgers University, who took his life after his roommate posted a video on the internet of his same-sex sexual encounter. The media highlighted a phenomenon that is not new; a study from the Suicide Prevention Center reports that lesbian, gay, bisexual, and transgender youth are between 1.5 to 7 times more likely to attempt suicide than their heterosexual peers. Media coverage focused on “bullying” and failed to connect these teen suicides to the larger issues of institutionalized heterosexism, homophobia, and transphobia.
Teen bullying and teasing based on gender identity or sexual orientation does not take place within the bubble of adolescent development, but as part of the larger world in which teens operate. One response to the reports of gay teen suicides was Dan Savage’s It Gets Better Project (www.itgetsbetter.org). A columnist, writer, and gay man, Dan Savage made a Youtube video addressed to gay youth. He encouraged other LGBTQ adults to post their own videos assuring youth that life improves as an LGBTQ adult. The response included videos posted by celebrities and notable personalities including Kate Bornstein, author of Hello Cruel World: 101 Alternatives to Suicide for Teens, Freaks and Other Outlaws and President Barak Obama.
I found myself wondering, as a clinical therapist, what role do I play in making sure that it does get better for queer youth?
In Philadelphia, I work with two agencies, and through my own private practice, to provide psychotherapy to LGBTQ communities. The Attic Youth Center is a community center for LGBTQ youth ages 13 – 23 that provides a range of free services, including therapy. Mazzoni Center’s Open Door program provides mental health services on a sliding-fee scale to both LGBT adults and adolescents. In my private practice, I see both individuals and couples from a range of sexual orientations and gender identities.
My choice to enter the field of clinical social work was driven by my fierce belief that all people deserve access to competent health-care serves, regardless of their sexual orientation or gender identity. Consequently, I navigate the challenge of holding two identities at once —activist and therapist. Transparency is a guiding principle in my therapeutic approach. This means that sometimes my activism overtly sits in the room with the client and me, while other times my identity as an activist simply guides me to provide a safe and non-judgmental space for my clients, where they reach their own conclusions about where (or if) they fit the LGBTQ community.
My perspective as an activist for LGBTQ rights plays a role in my clinical case conceptualization. During my clinical work with clients I often normalize their experiences. Sometimes this process includes sharing information about LGBTQ history and the diversity and fluidity of sexual orientation and gender identity. Despite television shows like Will & Grace, Glee, and other positive representations of gays in the media, LGBTQ youth still manage the accumulated trauma of fear and perpetual hyper-awareness on a daily basis. With few safe spaces to let their guard down, normalizing their experience in a counseling setting becomes even more important. Living with external discrimination, oppression and violence from families, communities and religious institutes leads to internalized hatred. This internalized homophobia and transphobia experienced by fellow activists and clients is profoundly damaging.
In Transactivism as Therapy: A Client Self-Empowerment Model Linking Personal and Social Agency author Rupert Raj describes how advocacy and activism can be integrated into the therapeutic process. (Journal of Gay & Lesbian Mental Health, December, 2007, pp.77-98.) That has been my clinical experience, too. One way I interrupt this pattern of internalized homophobia and transphobia is using activism itself as an intervention. I’ve found that supporting clients to express themselves as activists improves their self-esteem. In their new role as experts and teachers, they see themselves as someone worthwhile, with agency to make positive changes for the world around them, and ultimately for themselves. This increased self –esteem can lead to decreased depression or anxiety.
Providing clinical services within The Attic Youth Center and Mazzoni Center has been a unique experience; my clients are there because they are seeking services from a LGBTQ organization. There is a shared experience of being a sexual minority or ally as soon as they walk into my office. This shared experience provides an opportunity to look directly at the experience of living in the world as an LGBTQ person.
A clinical challenge specific to my work this population is providing space to safely acknowledge the pain and destruction that homophobia, heterosexism, and transphobia cause to my clients and their families. Encouraging them to engage in activism, whether through a political movement or by participating in a community event, can provide an outlet for the pain and anger of daily oppression; clients are empowered as they take steps to change the very mechanisms that have oppressed them.
Noah was a youth who came to me for counseling because he felt sad and depressed and hated his life. He had one past suicide attempt, and subsequent hospitalization, but was not in crisis when we began our work together. Noah was enrolled in a local college and struggling to both make friends and succeed in class. He said he hated being gay, and felt guilty for having those feelings. When Noah and I met he had no involvement in the LGBTQ community and was uncomfortable being in spaces with other gay people.
My work with Noah was marked by three turning points, and each was juxtaposed to an engagement in activism. After much discussion, Noah attended a meeting of the LGBTQ group on campus. He did not attend this group regularly, but after the first meeting things, Noah’s behavior and self-cognitions began to shift. He took more chances in social situations and became friends with peers in his classes.
Another week, Noah came in and told me that he came out as a gay man in one of his classes. It wasn’t something we discussed beforehand. Noah decided, in the moment, that it was the right choice for him, and it felt good. He spoke up in class about LGBQ rights, and wrote his final paper on same-sex marriage in the United States.
Finally, during his second year of college, Noah became involved in student activism on campus. He was voted onto the executive board of an organization that provided community service opportunities. Noah’s activism efforts did not always focus on his LGBTQ identity. What was valuable about these experiences was the opportunity for Noah to demonstrate to himself his ability to be responsible and worthy of love and respect. Although he still struggled with the homophobia he faced based on his sexual orientation, he was able to better manage his depression and anxiety as his sense of agency and his support system grew.
When my clients see my involvement in LGBTQ activism — which includes my work at The Attic Youth Center and Mazzoni Center I have the opportunity to model what it might look like to be out and support our community. My activism shows clients that I care about their well-being in the world as well as in session. I believe that this experience enriches the therapeutic relationship that I have with my clients. My commitment to activism mirrors my commitment in session to work with clients to help them make the changes that they seek.
Dan Savage’s It Gets Better Project has not been the only response to the LGBTQ teen suicides that were covered in the media. There have been multiple reactions and I believe that is what we need, multiple approaches to ending sexism, homophobia and transphobia within our institutions and systems. As clinicians we are uniquely positioned to incorporate activism into our clinical work – whether through our own actions, through our case conceptualization, through our efforts to stay aware of the challenges in our client lives or through supporting our clients to utilize activism as a clinical intervention. I feel that too often that individual therapeutic work with clients is not seen as activism.
For more information about providing inclusive and competent psychotherapy to LGBT populations see www.DMCConsult.net.
Damon M. Constantinides, LSW, M.Ed.
I Want to Be Alive and Present in this Moment
I want my life to be one of love, not rage
Kindness, not contempt
Joy, not suffering
I want to be alive and present in this moment,
not lost in thought and delusion.
- Zen poem
Early spring brings beauty into the harsh landscape of winter. It’s also a time a change. For some people change can be a scary thing, it can lift you off your feet feeling ungrounded and unsure of where you’ll land. People do all sorts of things to avoid this kind of change. But there are other things about change that are really beautiful and wonderful.
In his book about anxiety, Flying Lessons, Dr. John Snyder talks about anxiety as a feeling of movement, while depression is the lack of movement. From this perspective anxiety is a gift, it gets us off the couch and out of the house. It can be motivating and exciting, for example the best learning takes place when we feel a little bit of anxiety.
However, when we feel a lot of anxiety, we can feel trapped, unable to move, and afraid of change. It’s at these times that it can be helpful to take a step back, refocus, and pay attention to where you are right here, right now. The poem above, about mindfulness, describes one way a person might approach mindfulness. The author’s intention suggests that they do feel rage, contempt, and suffering, but are looking for ways to not allow those feelings to run their lives.
There are many ways to practice mindfulness. Some people find it in physical activity, working out by themselves and being in that moment. For others it’s found in nature, or simply sitting still for a minute with a cup of tea or coffee. Having this space amid the chaos of change can shift a scary situation to one that is manageable and maybe even exciting. Tiny Buddha is a website that often has articles about mindfulness, living in the present, and reducing stress. Two books that are also good introductions to mindfulness are The Miracle of Mindfulness by Thich Nhat Hahn and Wherever You Go, There You Are by Jon Kabat-Zinn.
From Good Therapy: Sex and Anti-depressants
Sex and Anti-depressants
February 23rd, 2011
By Jill Denton, LMFT, CSAT, CSE, CCS
Since my last blog a number of you have asked for more information about possible sexual side effects caused by antidepressants. Before I say more – a cautionary word – I’m a psychotherapist/counselor, not a medical doctor/psychiatrist! So what I write in this blog is drawn from my (extensive) experience working with people who have challenges and/or difficulties with sex – I’m a sexologist, not a psycho-pharmacologist!
Some of the worst culprits or libido smashers are the SSRI’s (selective serotonin reuptake inhibitors) such as Effexor, Paxil, Prozac, and Zoloft. Unfortunately, these are all heavily prescribed! I mentioned last month that many folks can benefit from a so-called “drug holiday” when they forgo their medication for a few days. Be aware that this intervention does NOT work for Prozac, due to the much longer time that Prozac remains in the bloodstream, compared with the other shorter-acting SSRI’s like Zoloft.
Several types of antidepressants have virtually no side effects. The most common that my clients have discovered are Wellbutrin, Xanax, and Klonopin. I’ll often suggest that new clients substitute (with the agreement of their medical doctor of course) Xanax or Klonopin for Wellbutrin because the latter can exacerbate anxiety or “agitated depression,” as it’s called by psychiatrists.
It’s also infamous for causing insomnia and headaches, which tends to make most of us anxious and certainly don’t contribute to enjoyable sexual connection! Wellbutrin is pharmacologically distinct from the SSRI’s as it enhances the neurotransmitter dopamine, which has the opposite effect on libido and orgasm of serotonin. Xanax and Klonopin are usually prescribed to combat anxiety, not serotonin, so they tend to have very few sexual side effects.
I will often recommend that people who are leery about psychotropics try St. John’s Wort, which is most effective, I’ve found, for Type A blood types (remember, I’m not prescribing, just using anecdotal experience to make these suggestions!) Because it’s not regulated as a pharmaceutical substance, I’m told that efficacy can vary widely among preparations.
Male clients have reported to me that Viagra is effective for SSRI-induced absence of orgasm, and I’ve known people of both genders swear by the botanical preparation ginkgo biloba to reverse libido, arousal and/or orgasm problems. One sex therapist colleague tells me that Viagra can be helpful for women as well, but none of my clients have reported this to me.
If switching to an alternative psychotropic is not clinically appropriate or effective, some doctors might recommend adding another medication on a daily or as-needed basis. Many people are hesitant about taking one drug, let alone two! But for those who are comfortable with it, a second medication can offer an antidote to the side effects of an otherwise helpful medication.
Most commonly a sexual savvy psychiatrist will prescribe a single low dose of Wellbutrin for clients complaining of sexual side effects from other antidepressants, employing lower does of Wellbutrin than would be necessary to treat depression. These small doses can restore the serotonin-dopamine balance that I mentioned earlier, alleviating sexual side effects.
People starting out with me often ask if I suspect that their sexual problems are relationship issues or caused by medication. I always ask them how long the sexual challenges have been occurring. SSRI-induced sexual dysfunction follows a fairly typical pattern: it begins within days or weeks of starting the new psychotropic medication. For example, a woman may report that she can no longer reach orgasm with her husband within weeks of beginning Prozac for obsessive compulsive disorder.
Women rarely volunteer this immediately, but I ask LOTS of questions, which makes it easier to discuss sexual hang-ups. Guys usually have less hesitation talking about such problems, and as one man said to be recently, “that’s why we came to a sex therapist and not the generic marriage therapist down the street!” The fact that I “coach” by phone also seems to help especially for men, who might have difficulty opening up “when the plumbing doesn’t work!”
Don’t forget – if you have questions about your medications, make sure to discuss them with your medical doctor or psychiatrist.
Link to full article: http://www.goodtherapy.org/blog/sexual-side-effects-antidepressant-medication/
