Tag: mental illness

Fatphobia in eating disorder recovery exists. And now my friend might die because of it.

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This is admittedly a long blog post, and a triggering one at that. For those of you who would like to help Shira but can’t read this post, please check out the fundraiser we started for her.

When Shira and I first connected, I had a feeling in my gut that we were meant to cross paths.

She had read my article on how I used body positivity to avoid confronting my years-long battle with anorexia nervosa, and we clicked immediately.

As a fellow blogger and advocate, no one could come closer to understanding how I felt than Shira did. (Not to mention, her winning combination of New York attitude and snark, and love of all things sparkly, captured my heart immediately.)

But at that time, Shira’s world was so incredibly small. That’s because, as an eating disorder therapist, Shira had kept her eating disorder a secret from her community.

While her organs were literally shutting down, and a terrifying fall left her badly concussed and her nose broken, she existed in a private hell that few knew about. The outside world only knew Shira as the same beam of sunshine and powerful advocate for body liberation she’d always been. But in private, Shira was dying.

In those earlier days of my recovery, Shira was a lifeline to me. To be honest, she still is.

Because even in the depths of anguish, Shira has the biggest heart of anyone I know. No matter how far down she’s fallen, she is a relentless cheerleader for those that she cares about, and the thousands of followers who have been inspired by her journey.

That’s because as a therapist, as a blogger, and as a friend, her sincere belief is that no one — not one single person — gets left behind.

Shira fought tooth and nail for four months in residential treatment, making enormous strides.

And while she was there, in a moment of extraordinary courage, Shira revealed to the world her 20-year-long battle with an eating disorder — putting her reputation as a therapist and advocate on the line to tell an undeniably powerful truth about the reality of eating disorders.

She wanted to affirm that, yes, eating disorders are a mental illness that doesn’t discriminate, even among healing professionals.

And even those who know everything there is to know about an eating disorder, about body positivity, about health at every size? Can still suffer from these relentless illnesses.

Her bravery in that moment has stuck with me every day in my recovery since then.

Throughout this past year, over texts and calls and audio messages on the train, we took on our eating disorders together. I watched Shira fight her way from the brink of death in a residential facility for four months, in awe of the grit and determination she showed up with day after day.

On the days when I didn’t want to keep going, she’d somehow telepathically sense it, I swear, because it would be less than five minutes later that I’d get a text asking, “What’s for lunch?”

After she was medically stable and eating consistently, it was time to transition to a partial hospitalization program back home, which would help ease her back into her daily life. We were both hopeful that she was well on her way to the recovery she so deserved.

Miraculously, she was able to secure a full scholarship for PHP, as insurance providers seldom cover eating disorder treatment. We were elated and hopeful.

I want to be able to tell you that, once in program, the momentum continued. But this is not that story. That program nearly destroyed her.

I don’t say that as an exaggeration. I say that as someone who listened helplessly on the other end of the phone, filled with rage, shock, and horror at everything my friend had to endure.

As an advocate, I’m not unfamiliar with the mental health care system and its horrors. As a survivor, I have stories of my own. But despite that knowledge and experience, what happened to Shira shook me to my core.

From day one, the first text I got from Shira about her new treatment team told me everything I need to know about the place: “They mocked Health at Every Size and the fact that I’m a therapist.”

My blood went cold. “Wait, what?” I typed back.

“Yeah,” she replied. “My case manager said, ‘Health at Every Size therapist? How does THAT work?’ And then when I tried to explain, she said, ‘Well, you seem to have ALL the answers.’”

But a snide comment from a case manager was just the tip of the iceberg. Things were about to get much, much worse.

The day program Shira was a part of had a “three strike” rule as part of a contract they require patients to sign.

In her gut, Shira knew that a strike system would bring out perfectionistic tendencies (a fear of failure is super common in folks with eating disorders). She voiced that, in the past, this sense of shame had sabotaged her recovery efforts.

Her concerns were brushed aside. They insisted that their “three strike” rule helps them determine if someone needs a higher level of care, and that these “boundaries” were an important part of the care they provided.

This became a pattern, though: Whenever Shira tried to voice that something wasn’t working, she was told that her “malnourishment” and her eating disorder’s “tendency to manipulate” made her an unreliable advocate for herself.

This part, of course, comes as no surprise to me. Clinicians often treat people with mental illnesses as if they aren’t competent enough to vocalize their needs and expectations.

But the strike rule would become a sticking point, because within one month, Shira — despite all of her success in her four months of residential care — would accrue all three of her allotted strikes.

The first strike happened when she refused to eat ice cream. She did so not because she was unwilling to eat it, but because of the instructions her dietician gave her cohort.

“The dietician said, ‘You three get two scoops of ice cream.’ She then looked at me and said, ‘You’ll get a kiddie scoop.’”

Some of you won’t understand the gravity of that comment. To be clear, a dietician told a patient with anorexia nervosa to eat less food than her peers, because she is a patient in a larger body.

The message here being, of course, that Shira needed to eat a child-sized portion of ice cream, because she wasn’t thin enough to “safely” consume more than that.

This plays directly into the eating disorder’s conviction that she needed to tightly control her food intake and her body. Her peers could eat a “normal” amount of ice cream. But she couldn’t and was singled out, because something was “wrong” with her body.

“This was the message I received my entire damn life,” Shira told me. “That I couldn’t eat like everyone else.”

This dietician perpetuated a fear of food and implicitly encouraged restriction, all of which are absolutely inappropriate to suggest to someone with anorexia nervosa, regardless of size.

Restriction is never an appropriate recommendation for someone with an eating disorder.

And yet that’s what she was told… in a prestigious treatment center.

Shira refused to eat the ice cream, grappling with an immense amount of shame, self-loathing, and fear. And by refusing to eat the ice cream, Shira earned her first strike.

This became an ongoing problem in treatment, in which she was told, for example, to eat 70% of her sandwich (yes, seriously). It left her feeling guilty about eating, and when she was still hungry afterward, she wondered if something was wrong with her.

Even after the center agreed to stop controlling her food intake with numbers, the damage had already been done — she knew she only “needed” to eat a percentage of what she was given, both from what she was told and what she overheard when other patients were given their food.

She began to backslide in her recovery.

Prescribing restriction for larger patients, though, wasn’t the worst part. It was the silencing of Shira’s voice, particularly around size inclusion.

Whenever Shira tried to address the complexities of recovering in a larger body, she was shut down by clinicians and peers alike.

She was discouraged from discussing her fears around returning to a bigger body, as someone who had lived in one most of her life, and understood that her recovered body would likely be a fat one.

“I needed them to acknowledge, just ACKNOWLEDGE, that recovering in a fat body is terrifying in a world that hates fat people,” she texted me once.

Instead, she said, they remarked that she needed to “take her therapist hat off” and suggested that she was being difficult, and lacked commitment to her own recovery.

Being surrounded by a treatment team that couldn’t validate her fears, suggested that she restrict her intake, and questioned her investment in recovery, began to erode her sense of faith that she was supported.

Shira accumulated two more strikes as she continued to struggle. And rather than ask how they could better show up for her, they called her in for a meeting, and immediately blamed her for not progressing quickly enough.

That’s when they told Shira she needed to start calling residential centers, and ‘prove’ that she wanted to recover.

I remember how she described the heartbreak, realizing that her treatment team didn’t at all honor how hard she had been working, nor did they hear her when she explained how she needed the space to talk about recovery in a larger body.

She felt defeated, wondering if she had failed. Calling her outside providers, the feedback from her external therapist and dietician was unanimous: Shira didn’t need to go back to residential. She needed trauma-informed, size-conscious care at the outpatient level.

Having accrued three strikes, though, the contract dictated that Shira couldn’t continue in their program.

Shira didn’t want to give up. After meeting with her therapist, she sent a powerful email to her treatment team at the center, explaining that she would like to come back.

She reiterated her commitment to her own recovery, expressing that she simply wanted a care team that could affirm her experiences of fatphobia in the outside world, and one that could create an environment that had more consciousness around what might trigger someone in a larger, recovering body.

After sending that email, she heard nothing for two days. Wracked with guilt and self-blame, she relapsed — hard.

How could she not? In their last meeting, she was blamed for being unable to “comply” with treatment, and was told over and over again that her “manipulative” eating disorder was making it difficult — if not impossible — to help her.

When she finally heard back, she was invited to meet with her treatment team again… one week from then. Mind you, Shira’s outside providers have been contacting the center, warning them of the relapse and acute state that Shira is in.

This is the same center that told her that she needed to come to their center within an hour of her plane landing, for fear of being left with any lapse in care. Now, they’ve told her to wait an additional week to “discuss” the future of her care.

When Shira asked what she should do to keep herself safe in the meantime, the answer was short. “You left,” they told her, not acknowledging that the contract they had her sign meant she was being kicked out.

She was told to rely on her outside providers, suggesting that maybe they could’ve come up with an alternative if she hadn’t left.

Once again, the buck was passed.

Shira spent that entire week unable to afford much care from outside providers and, in an acute relapse, she unraveled quickly.

She and I held out hope, though. After all, why have a meeting at all if not to discuss how they could help her? I had read the email Shira sent, and it was gracious and encouraging, emphasizing that she was hopeful that they could find a path forward.

Clearly they were going to regroup and find a way to support her, I thought. Her email was so reasonable, and it was a powerful moment of self-advocacy for someone who struggled to find her voice.

But I thought wrong. After a week-and-a-half without care, now navigating a dangerous relapse brought on by her traumatic treatment experience, Shira attended a “meeting” with the center.

I put “meeting” in quotation marks, because it wasn’t a meeting at all. They, instead, took it as an opportunity to reiterate her failures under their care.

They told her that they would be discharging her and revoking her scholarship. Their rationale? She was ‘non-compliant.’

They went on to tell her that it was a “slap in the face” that, after being given a scholarship, she wasn’t trying harder. Shira listened, heartbroken and in shock, as she was told that she was to blame for her treatment being unsuccessful.

They would not be helping her secure care elsewhere. They called her into a meeting to simply tell her she had failed.

They knowingly allowed Shira to relapse for a week-and-a-half with a deadly mental illness, and kept her in limbo with no intention of helping her, for what reason, exactly?

They could’ve told her from the beginning that she needed to arrange for some other form of care. They could’ve offered some kind of contingency support to transition out of their care. They, at the very least, could’ve called her on the phone earlier rather than have her wait.

“She’s in a bad way,” one of her outside providers warned them that week, impressing upon them the dire stakes. During that week, Shira was fainting, and again at risk for serious esophageal injuries due to her purging behavior, which had reemerged fiercely during the relapse as she struggled to cope.

No one can know for certain why a clinical team would deliberately string someone along in an acute crisis in that way.

Only they can answer to that.

That’s where we find ourselves now: Shira was abandoned by her day treatment team, and she cannot afford another program.

Furious doesn’t even begin to describe how I feel, watching this all unfold from a distance.

Shira is dying — there’s no other way to describe what happens to our bodies in these states of ED relapse. And the hope she once carried for a life on the other side of this was pummeled by clinicians she had trusted to support her.

But somehow, she still wants recovery. After everything that’s happened, she still wants to fight. Not that I’m surprised, because Shira already sacrificed so much to get to where she is.

But after everything she’s endured, both at that center and others, I wouldn’t have blamed her at all if she’d given up.

And this is the part where I get extremely, uncomfortably honest with you all: I don’t want to lose Shira. I can’t lose Shira.

That’s why I’m part of a team of friends and advocates in the community that’s started a GoFundMe to support her treatment.

This is the first fundraiser like this that I’ve ever been a part of, and believe me, I wouldn’t be asking if this weren’t important to me.

I believe that the advocacy and clinical work that Shira does is invaluable, and it’s work I want to continue doing alongside her. I want to believe that those of us with mental illnesses can recover, and go on to help others — as healers, as writers, and YES, as therapists.

I want Shira to continue to be a shining example of what happens when those of us who are wounded go on to become healers.

But Shira needs help — desperately. And somewhat selfishly, I don’t want to do this whole recovery thing without her.

I want us both to get better. I want us to start our own treatment center one day (I’ll admit, Shira is making me seriously consider becoming a therapist myself), to fight for policies that protect people like us, and hold accountable any and all clinicians who do harm to their patients.

I have already watched so many of my friends die, fighting to the very end to access care. I don’t know how many more people I can lose this way.

I know you probably see hundreds of GoFundMes every week, floating across your screen. And I won’t try to convince you they aren’t all worthy of your support.

But this one, for me, is personal. Because of everything Shira represents, but more than that, because of everything she’s done to pull me out from the depths of my anorexia, even as she struggled with her own.

Please help Shira, so she can continue to help, uplift, and empower others.

I don’t want a fatphobic, negligent system to be the reason her precious light leaves this world. I don’t want Shira to become a statistic, exemplary of all the ways this system fails so many of us.

She deserves to live. She deserves compassionate, trauma-informed care. We all do.

And she still has a chance — and all she wants is to recover, so she can dedicate her life to helping others do the same.

To learn more about the fundraising effort and Shira’s amazing work, take a look at the GoFundMe I helped create.

And if nothing else, I want to make one thing crystal clear: Neither of us are going down without a fight.

Because no one, especially at their most vulnerable moment, should have to go through what Shira has. And we both want to keep fighting to change that.

And we fucking will.

I preached body positivity — and sunk deeper into my eating disorder at the same time.

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I don’t usually write about my mental health when things are “fresh.”

Not in the last couple years, anyway. I prefer to let things marinate, and to make sure that the words I choose are empowering, uplifting, and most importantly, resolved.

I prefer to give advice when I’m on the other side of something — largely because I know I have a responsibility to my readers, to make sure I’m nudging them in the right direction. I know this blog can be a lifeline for folks who need something hopeful. I try to remember that.

But sometimes, when I perfectly package that hope for an audience, I can delude myself into thinking that I’ve cracked the code and, therefore, can tidily leave a struggle in the past. The perfect conclusion to the chapter, as it were.

“I know better now,” I think to myself. “I’ve learned my lesson.”

If you were to Google “transgender body positivity,” I’m fairly sure more than a few things I’ve written will come up. I’ve been interviewed for podcasts and articles, and hoisted up as an example of a trans person who — in a simple shift in perspective and following the right insta accounts — came to redefine his relationship to food and to his body.

Three articles that appeared in a Google search for "transgender body positivity," all written by Sam.
I wrote all three of these. Delightful.

That version of events is one that I love, because it’s so simple and comforting. One shiny, bright epiphany, and I emerge victorious, having evolved beyond any worldly, frivolous concerns about my stretch marks or eating ice cream for breakfast.

“Fuck you, diet culture!” I jubilantly exclaim. “I know better now. I’ve learned my lesson.“

When you are a mental health advocate and writer, especially in such a public way, it’s easy to trick yourself into thinking that you have all the answers to your own problems. But that illusion of control and self-awareness is exactly that — an illusion, and a deceitful one at that.

It’s easy to point to the years I’ve spent in this space, and everything I’ve published about this exact thing, and insist I’ve got things under control. It’s not my first rodeo, pal. Or second. Third. Fourth. (I’ve got experience on my side.)

If I can support others through their recovery, surely I can navigate my own. Even as I write that, I know it’s patently ridiculous — giving good advice is much easier than applying it to yourself, especially where mental illness is concerned.

But the version of me that I prefer is the one that said in this interview, as recently as last June, “When you get to the other side of whatever you’re struggling with, you’ll see that not taking those chances — living only half the life you could’ve been living — is a lot scarier than any disaster you imagined would come from eating that slice of cake or whatever it was.”

Says the person who is, really and truly, living in that fear in a life half-lived right at this very moment.

Body positivity has felt like a relationship I dove into at such a young age, long before I knew myself or even my eating disorder. And once I was in too deep, having positioned myself as triumphant, I didn’t know how to step back enough to ask for help.

I wanted to believe it was like an incantation I could say in front of the mirror several times — “all bodies are good bodies! all bodies are good bodies! all bodies are good bodies!” — and POOF! I was absolved of any guilt, shame, or fear I felt around food or my body.

I could say all the right things, like a script that I’d rehearsed, and love the idea and the image of myself when I peered through those rosy-colored lenses.

But where eating disorder recovery is concerned, a script — even when memorized — is not a substitute for the work.

And no amount of Instagram memes and photos of belly fat could touch on the old, painful wounds that had positioned food as my enemy, and my body as the site of a war.

Which is all to say, I am not recovered. The work hadn’t even begun. In fact, I used my proximity to body positive spaces to disregard the very idea that I needed help — and I’m paying the price physically, mentally, and emotionally now.

I wore body positivity like an accessory, to project the image of myself that I wanted to be, and my eating disorder reveled in the idea that I could suspend the reality of my illness simply by curating my social media accordingly.

My understanding of body positivity — and by extension, its roots in fat acceptance and liberation — was shallow at best, but only because my eating disorder thrived so long as I sustained the illusion that I knew better. This was yet another way of convincing myself that I was in control, that I was smarter than my ED.

My disorder had a vested interest in lulling me into a false sense of security. I couldn’t have an eating disorder, I thought — disordered eating, maybe, but who doesn’t? I couldn’t because I was evolved. As if mental illness ever gives a fuck about the books you’ve read.

Eating disorders have a way of sneaking up on you. That realization is a new one for me — not because I didn’t logically understand that, but because I’ve only come to accept it in the context of my own lived experience in the last few days.

And I wish I could say that this epiphany came to me on my own, inspiring me to reclaim my life, but there’s no such heroism here. It came to the surface only because my doctor asked the right questions during a routine checkup, and my bloodwork revealed what I feared to be true — my body was coming undone in the absence of adequate, much less nutritious, food.

“I don’t understand how people decide when to eat,” I confessed to my therapist. His eyes widened with deep concern.

“They eat when they’re hungry, Sam,” he said gently.

At some point or another, I had utterly forgotten that simple, basic fact. There is a mechanism in the body, intended to guide me, and I’d cut all ties to it completely.

I don’t share this as a criticism of myself, but rather, as a very simple truth: Many of us who are lauded as faces of recovery are still, in many ways, right in the thick of it along with you.

Sometimes what you’re seeing is not a portrait of success, but rather, a small piece of a more elaborate, messy puzzle that we’re frantically trying to assemble behind the scenes, so that no one notices that we’re in pieces.

My eating disorder recovery is, in truth, in its very infancy. I’ve only recently stopped using “disordered eating” to obscure the reality, and this morning, finally spoke to a dietician that specializes in EDs.

This morning.

Today is, in actuality, the first real day of recovery. That’s three years after, by the way, I wrote these words: “No more justifications. No more excuses. Not another day . . . this is not control.”

I know there are readers who might have looked at my work in body positivity, and absorbed the misguided notion that eating disorders (or any kind of body negativity or food aversion) are simply mazes that we think (or in my case, write) ourselves out of.

If that were true, I wouldn’t be sitting here, sharing with you a very uncomfortable truth about recovery: There are no shortcuts, no mantras, and no quick fixes.

And as we glamorize the idea of an easily attainable self-love — as though it’s just one perfect crop top away — we miss the deeper work that must be done within ourselves, that no amount of sparkly, inspirational quotes we retweet can replace.

Trauma is not on the surface, and to strike the heart of it, we have to go deeper.

This is an awful and uncomfortable truth that I am coming to grips with — mainstream, watered-down body positivity can open the door and invite us in, but it’s up to us to do the real work of recovery.

And that begins not externally, but within us. Recovery is an ongoing commitment that we must choose every single day, deliberately and courageously, with as much rigorous honesty with ourselves and our support systems as humanly possible.

No matter how we curate our social media to remind us of where we’d like to be, the aspirational vision we create is never a substitute for the reality that we’re living in.

As is so often the case with eating disorders, I’m realizing, the aspiration — that “what could be” — so often becomes a compulsive, maddening drive, where we live in a future that we never arrive at.

And unless we commit ourselves to being grounded firmly in the present, even (and especially) when it’s uncomfortable to be here, we relinquish our power and fall under its spell.

My ED loved the naïveté of Insta-friendly body positivity, leveraging that illusion of safety to delude me into thinking I was in control, that I was better than all this.

And I can’t say I’m surprised by it — EDs seem to take many of the things we love (ice cream, yoga, fashion) and turn them against us in some way or another.

I don’t have all the answers, except to say this: We are works in progress, all of us, even those that you look up to. A pedestal is a lonely place to be, and loneliness, I think, is where eating disorders (and many mental illnesses) often thrive. I’ve been up here for too long, silently waiting to fall or for it to crumble underneath me — whichever came first.

As I make my descent, slowly climbing down from the pedestal and stepping into the light of my recovery, I’m going to embrace the truth that every one of us needs to remember: It is okay not to be okay.

It’s okay to not have all the answers, even if the rest of the world expects you to, even if you expect yourself to.

I am not, as some people have described me, “the face of transgender body positivity.” If I am, I don’t want to be — I don’t want any of us to be if that means we’re not allowed to be human.

I want you to scrub that image from your mind and, instead, know where I really was yesterday: Clinging onto a nutritional shake for dear life (literally — it’s kept me alive these last few months), having not showered for three days, while texting the words “I think I need help.”

So many of the advocates you look up to have had equally unromantic but profoundly brave moments just like that.

We do every single day, whether we have a selfie to prove it happened or not. (Some of us have group texts, and trust me, we are all on the Hot Mess Express together. Promise.)

If you’ve felt like you’re not allowed to “fail” (or rather, have an imperfect, messy, even fucked up recovery), I want to give you permission to live that truth, with every bit of honesty and vulnerability that you need.

It’s okay to let go of performing recovery. And trust me, I know how big of an ask that is, because that performance has been my security blanket (and the source of my denial) for so, so long.

You can surrender to the doubt, the fear, and the discomfort that comes with doing the work, and give yourself permission to be human. You can let go of that control and — I’m told, anyway — it will all be okay.

And this amazing community of recovery warriors that we’ve created with our memes, our inspirational quotes, and our crop tops? We will be right here, waiting to support you.

I can’t say that I know this for certain (hello, Day One), but I have a strong suspicion that this kind of honesty is where the real growth happens. And wherever there’s growth, I’ve found, that’s where the healing truly begins.

And that’s what we deserve, every one of us. Not the aspirational kind of healing, but the deeper stuff.

I want that for me. I want that for all of us.

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Struggling with food? Body stuff? Or just need someone to talk to? The National Eating Disorder Association (NEDA) is a wonderful place to start. They’ve been an incredible resource for me — and I hope they’ll be for you as well.

Before you go…

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This blog is not sponsored by any fancy pants investors that are trying to sell you stuff.

It’s funded by readers like you via Patreon!

Every donation counts. Help keep resources like these accessible to everyone that needs them! And help buy me a cup of coffee, because I write a lot of these blogs after work, late at night, so I could definitely use the caffeine.

Photo by Laurenz Kleinheider on Unsplash

If your ‘suicide prevention’ isn’t talking about the mental health system, you’re missing the point.

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As both a suicide attempt and loss survivor, I need to climb up onto my soapbox for a minute.

Suicide attempts, from a “preventative” standpoint, are rarely, if ever, as easily prevented as calling a hotline or a loved one. “Reaching out” — while incredibly important — is not the be-all-end-all of preventative strategies.

Especially considering the fact that many of us have a history of asking for help, and not getting the care that we needed.

I understand the impulse to ask, “Didn’t they know they could call me?” I asked myself that many times when I lost one of my best friends earlier this year. But this shows a very big misunderstanding of the emotional experience that many suicide attempt survivors have described.

Speaking from my own experience, when you are in a very acute amount of emotional distress, your thought process is not as linear or composed as you might assume.

The pain in that moment can eclipse everything else — past, present, future. It’s a sort of tunnel vision in which the pain becomes too great; in those moments, I’m cognitively incapable of stepping back to get the kind of perspective I might otherwise have.

This is why I always try to remind folks that suicide attempts don’t necessarily reflect a person’s overall state, as much as it does their level of pain in that particular moment.

To put it as a metaphor, suicide attempts remind me quite a bit of heart attacks, in the emotional sense.

After a certain point, the body’s resources can no longer fend off a very acute and painful event. It is so pronounced that your brain’s reaction is to scramble and do whatever is necessary to combat that pain, as immediately as possible.

We have some autonomy when we’re in that kind of pain. But so many of our actions are ultimately driven by the visceral agony we’re in. Our systems are flooded and overwhelmed, made worse by the adrenaline, the stress hormones, and for many of us, whatever substances we might be abusing — like alcohol — in a misguided attempt to cope.

But more often than not, unlike a heart attack, it’s also a pain that’s been building for weeks, months, or even years.

When we talk about “suicide prevention,” we focus too much on trying to understand the actual attempt, and not enough on accessibility of care.

We don’t do much to ensure that the pain doesn’t become that acute in the first place. We don’t focus enough on quality of life afterward. And most importantly, we rarely interrogate the systems in place that have failed to support them long before they reached this place.

It’s as though we’ve seen someone having a heart attack, but we start asking what they had for dinner the night before, or kicking ourselves for not offering them aspirin that morning.

When we talk about addressing heart disease, we’re not just trying to intervene in the mere moments before they happen — we know that isn’t enough, which seems like common sense in this context.

We talk about the whole person, and all of the ways in which their wellbeing needs to be prioritized well before they reach a crisis point.

But suicidality is still not viewed this way. We treat suicide attempts as very deliberate choices, rather than complex reactions that we know are better addressed sooner, not just puzzled over later.

The problem is, our mental health system isn’t set up to intervene at the moment when it’s needed.

Therapists and psychiatrists are still wildly inaccessible. And if you can find one that has availability and is covered by your insurance (assuming you have insurance), it often takes weeks, even months before you can actually see them.

If that clinician isn’t competent or a good fit? That’s additional weeks, months, and even years until you find someone who meets your needs. Which doesn’t include the months it takes for those treatments to start yielding real results.

I recently wrote a reported piece about a veteran with PTSD, for whom the nearest mental health provider that took his insurance was a staggering four hours away by car. And if he hadn’t had access to a vehicle? I’m not sure he would still be alive right now.

And all this assumes that mental health care isn’t so stigmatized in your community that you feel empowered to get help sooner rather than later, which is simply not the culture we live in.

This bureaucratic nightmare, combined with stigma, is why many people with mental health struggles often don’t seek help for nearly a decade (or more) after their symptoms set in, if they seek help at all.

And that’s why I bristle at the questions I so often hear after a suicide attempt. “Why didn’t they ask for help?” is the wrong question to ask. “What were they thinking?” is the wrong question to ask.

“What did WE do to help them, as a society?” is the question here. And more specifically, what were WE thinking, when we set up our mental health system to be so inaccessible?

I want to challenge us to think about what we’re doing to change this on a substantive, systemic level. This isn’t about reaching out. This is a call-to-action.

My own suicide note years ago simply read, “I’m sorry. I just can’t do this anymore.”

Not, “I don’t want to do this.”

Not, “I don’t have any other options.”

Not, “I don’t care about my loved ones.”

I simply said, “I just can’t.” I had reached a point at which I truly believed that I could no longer physically withstand the pain that I was in.

This led me to the emergency room and, even there, I saw people desperately trying to harm themselves by any means they could, being stopped only because they were restrained by hospital staff.

And this was not because they didn’t have “help” or “options.” It wasn’t even because they weren’t asking for support. They were in the hospital — they were surrounded by people who, in theory anyway, wanted to help them.

But their pain was that unbearable, that all-consuming.

How do you bring someone back from that? And more importantly, how do you make sure they don’t return to that place?

Beyond preventing the act of attempting suicide, I want to know how we can assure them that the life they’re returning to is one in which they are truly supported.

No one should ever get to a point of experiencing that much pain. And if they do, there should be no question of what resources are in place to guide them through recovery. But our system isn’t built to intervene sooner rather than later. Our system isn’t built to create a reliable, consistent safety net afterward.

It’s certainly not interested in establishing any real quality of life, so much as it focuses on simply preventing death.

We have a “worst case scenario” mental health system, and it’s failing. Its efficacy is a game of luck at best, a roll of the dice.

If you have insurance; access to transportation; the right combination of clinicians, inpatient or outpatient programs, and/or medications; the time to commit to recovery; the persistence to keep following up with providers; the support system around you to help you when this becomes overwhelming; and the sheer energy to navigate the system that is already overburdened — maybe, just maybe you’ll survive.

No one’s livelihood or quality of life should be left to chance.

I’m not trying to paint a bleak picture. People can and do thrive, and I’m absolutely an example of that.

But not because our system is actually successful at what it does — it’s because I am one of the lucky ones that eventually, after many years, found my way through it.

I can tell you why I attempted suicide years ago, and it’s simple: the amount of time it took to “recover” exceeded the amount of resources I had to cope.

It took eight years to get the proper diagnoses for my mental health conditions from the time I started therapy at age 17.

Which means it took eight years to find the right medications to treat my OCD, PTSD, and ADHD. And it took eight years to find a therapist that specialized in those areas — a therapist that I had to pay out-of-pocket for, because my insurance wasn’t taken by any therapists in the area who had openings for new clients.

I’m less interested in preventing the act of suicide itself, and more interested in knowing why our system is doing such a terrible job of caring for people who are struggling before, during, and after.

When we know earlier and more compassionate interventions are so critical, and when we know quality of life is exceedingly more important than simply keeping someone alive, we need to start asking why our system is set up the way it is.

We need to start demanding that something change — because our lives depend on it.

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Hey there, friend. Before you go, I want to share some resources with you.

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If you’re suicidal, call the National Suicide Prevention Lifeline at 1-800-273-8255, the Trevor Project at 1-866-488-7386, or reach the Crisis Text Line by texting “START” to 741741.

This isn’t just a generic “here are some numbers” plug, I promise. This is a “I want you to stay, we need you here, please don’t go just yet” plea.

Are you a loved one that wants to reach out to someone you think is struggling? Incredible. You totally should.

I have a guide here for how you can offer support in concrete ways.

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One more thing: I created this resource totally for free, but your donations help keep this labor of love going.

This blog is not sponsored by any fancy pants investors that are trying to sell you stuff.

It’s funded by readers like you via Patreon!

Every donation counts. Help keep resources like these accessible to everyone that needs them! And help buy me a cup of coffee, because I write a lot of these blogs after work, late at night, so I could definitely use the caffeine.

 

Some credits & gratitude go to… Photo by rawpixel on Unsplash. Artwork by Jessica Krcmarik.

If your goal in therapy is to ‘be happy,’ you might want to rethink that. Here’s why.

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When I first walked into a therapist’s office when I was eighteen years old, I had one goal and one goal only: “I just want to be happy,” I said.

Up until that point, I couldn’t really remember what that felt like. I didn’t know at the time that I had obsessive-compulsive disorder (as it turns out, it runs in the family), and that my near-constant state of guilt, panic, and rumination wasn’t actually the way most brains operate.

I thought happiness was the whole point of this “mental health” thing. So I became something of an emotional hypochondriac — if I wasn’t happy, something was wrong.

Suddenly my very human experiences like sadness, anger, and anxiety were all “problems” that needed to be “fixed.” I had this unreasonable expectation that, if I worked hard enough, I could minimize the presence of every other emotion to become capital-h “Happy.”

That’s not exactly the healthiest mindset, if you really think about it.

Ask anybody what they want out of life, and they’ll probably tell you the same thing I told my therapist all those years ago — it’s about being happy, isn’t it?

But happiness is just one emotion. And humans aren’t built to experience one emotion and one emotion only.

So we set ourselves up for failure. We internalize this idea that life is about sustaining something that can’t actually be sustained… but we pretend that, with the right attitude, it can be.

And then we wonder why we keep getting let down. It just doesn’t leave room for the whole spectrum of emotions every one of us is going to feel.

The thing is, if our goals for therapy (or recovery generally, or even life) are setting us up for failure, they aren’t really serving us. In fact, they’re probably going to discourage us. This becomes doubly true when we’re talking about marginalized people, where societal circumstances basically make it impossible to be happy all of or even most of the time.

And if your goal for therapy is impossible? You might give up before you ever get to the good stuff.

The really paradoxical thing about mental health recovery is that the goals that lend themselves to happiness usually aren’t about happiness at all, at least directly. A lot of people find that the less they focus on “being happy,” the more they’re able to make changes that contribute to their happiness.

Being happy with greater frequency and intensity just becomes this weird (and totally cool) side effect. At least, it was for me.

So if you’re not going to therapy or living life to become happy, what’s the point? I started asking the same thing. And what I learned along the way kind of blew my mind wide open.

If you’re wondering what might be helpful to work towards (whether it’s with a therapist, a life coach, a spiritual guide, in a support group, or even as prompts for your journal), that’s what I’m here for.

Here are five goals that I’ve found to be especially important for therapy — and why ‘being happy’ isn’t one of them.

1. I want to live a life that feels more meaningful.

Arguably every goal on this list circles back to this one. There’s an awesome TED talk by psychologist Emily Esfahani Smith unpacking this exact thing (I highly recommend it — it’s based off of a book she wrote that’s rooted in her work in positive psychology, pulling not just from research, but also from philosophical and spiritual traditions).

We can’t be happy all of the time, but if we can create a greater sense of meaning, it gives us something even better — a life that feels worthwhile. It can motivate us to invest in ourselves, our communities, and our world in a way that doesn’t depend on whether or not we’re happy in a given moment.

In other words, it’s more sustainable. Smith outlines the key pillars of a more meaningful life by breaking it down into four categories: belonging (feeling affirmed by people around you), purpose (serving others in some way that reflects our values), storytelling (which I’ll talk about a little more below), and transcendence (moments that fill us with awe or wonder).

I personally found belonging by joining groups in my local queer community and purpose by volunteering locally around causes I care about. I’ve found transcendence by going to concerts and becoming a drag performer (music and art have always made me feel like I’m a part of something bigger) and traveling a little more.

It’s worth mentioning, I was able to do this after I found the right balance of psychiatric medications to better manage my obsessive-compulsive disorder and ADHD.

So I do recognize that this requires a strong enough foundation on which to build — luckily, a shift in goals can help us determine what exactly we’re working towards which can inform what kind of support we need.

2. I want to create a better narrative for and about myself.

I’ve heard many times before that who we are is just a compilation of the stories we repeatedly tell ourselves — whether we realize that or not.

For the longest time, I’d written myself off as some neurotic, broken person that just needed to be “fixed.” And that deeply impacted how I treated myself and the choices that I made.

Working with a trusted therapist and even blogging about my experiences helped me construct an entirely different story for myself. In processing and unpacking my life experiences, I could see more clearly that I had done my best, learned from my mistakes, and emerged on the other side a stronger and more determined person.

I realized my identity was simply an interpretation of all the events I could remember. And as it turned out, there were many different ways to interpret those events that I’d never thought of.

Up until recently, I chose to interpret difficult events in my life as a reflection of my own inadequacy and failure, rather than a journey of personal growth and new insight. Practicing this reframing of my life, especially with a therapist, helped me construct a new story and a new appreciation for who I am and who I’ve become.

There’s actually plenty of research that backs this up, too; internalized narratives play a big part in our overall satisfaction with life.

The tricky thing is, we’re not always aware of the stories we’re telling ourselves (the fish in the bowl doesn’t always see the water, after all).

But when we uncover these narratives, and start to question where they came from and what we can learn from them, it can make a big difference in how we perceive ourselves (and by extension, how we feel and behave — cognitive-behavioral therapy, anyone?).

I don’t believe for a minute that we “choose” to be happy or unhappy. I do believe, however, that brains are pretty malleable things — and with practice and support, we can find a different story to tell ourselves and learn to believe in it, too.

And if our identities are really just the interpretation of a life story, those interpretations can change our whole selves.

3. I want to cultivate more intimate, fulfilling relationships.

Our relationships play a big part in our day-to-day. I’m constantly amazed, as I do more work with a therapist, at how often I’ve gravitated towards toxic relationships without fully realizing it.

Many of us have patterns in how we engage, the kinds of people we seek out, and in what ways we invest in others (or don’t). Just a few weeks ago, I wrote about one of my worst patterns as a people-pleaser. I suspect we’d be a lot more satisfied in life if we were more aware of these things, but that awareness takes work.

Being more aware of our relational patterns is an awesome goal, and it can wind up making us happier in the long run. It benefits ourselves, the people we care about, and the communities in which we live.

If you’re not sure where to start, there are some questions worth considering:

  • Who are the people I spend my time with? How do I feel before I spend time with them and how do I feel after? I wasn’t able to answer the second question at first, so I had to start being more mindful when I hung out with people. And let me tell you… it was mind-blowing to see how some of the people I invested in most made me feel worse.
  • How do the people closest to me express their care, investment, and affection for me? How do I reciprocate and how often? This helped me to become more grateful for the generosity that I wasn’t always the best at noticing, and also made me aware of the relationships in which I was giving a lot more than I was receiving. (Relationships are rarely an equal transaction, but being mindful can help us make better decisions around where we want to invest our energy.)
  • Who are the people, if any, that hype me up? And how can I find them or connect with them more regularly? I sat down and thought of three people that consistently make me feel good about myself. And no joke, I threw them in a group chat on Facebook and now we get brunch together most weekends. I even have a spreadsheet where I keep track of the relationships I’m nurturing. I can honestly say that my life improved instantly when I did this.

If you don’t have close friends or loved ones that hype you up or make you feel good, that’s also important to know. It might be time to start expanding your social circle, whether that’s online or off!

4. I want to develop resilience and healthy self-reliance.

I’m by no means saying that pursuing happiness is totally futile! It’s important to do things that you love and bring happiness into your life.

But I also think, along with seeking out joy, it’s a good idea to couple it with learning how to cope with the difficult stuff, too.

Being happy is awesome, but being able to roll with the punches becomes really important at those times in which happiness isn’t feasible or possible (because your boss is the worst, or the president tweets again, or life just happens to suck for a while — it happens!).

When there’s a setback, how quickly do you bounce back? Are there ways you’d like to be able to take care of yourself, but find are difficult to do? In other words, how often do you feel helpless or stuck, and are there opportunities to change that?

Rather than becoming unhappy and looking to “fix” it, berating myself for feeling negatively, or getting flustered as I tried to figure out how I got there, I started accepting how I felt in the moment. After all, thoughts and feelings come and go, because that’s kind of how brains work (they are super imperfect meat machines, basically).

So while waiting for the clouds to pass, I started grounding myself in the moment and asking, “What can I do, right now, to make this moment a little better?”

Therapy, for me, has been the best route in learning new coping skills (along with antidepressants, because sometimes our brains need an assist). But I realize not everyone can access super great therapy (a rant for another day).

That’s why I’ve written about mental health apps that can teach you some new skills, shared many of my favorite self-care resources for those that might need it, and am a strong advocate for self-help books, online communities, and support groups. The internet can open up access to a lot of these things. Go forth and educate thyself!

Resilience is an important goal (or process really). It allows us to live in a world that’s constantly changing, and gives our brains permission to be the finicky and unpredictable things that they sometimes are.

5. I want to uncover where I’m making life more difficult for myself.

Everyone on the planet has self-defeating patterns. I mean, I don’t necessarily have any research to back this up, but I have yet to meet someone that doesn’t shoot themselves in the foot with some regularity.

Some people with depression make themselves sad on purpose because it feels “safe,” as an example (I explain more about why in this post).

More often than not, the coping skills we developed when we were younger aren’t so great for the adult world. The rules and environment are completely different (and also, we likely just weren’t as skilled in general at taking care of ourselves — wisdom and experience and all that).

Recently I noticed just how much avoidance makes me miserable. I’d avoid things that stressed me out (like going to the dentist or answering important emails), without fully acknowledging that I was only prolonging my pain.

But here’s a fun discovery: The momentary discomfort of facing what stressed me out was a lot easier than the lengthy, drawn-out anxiety attack that occurred while I put things off.

The more I plugged my nose and walked through the stuff that I hated but needed to face, the easier and easier it became to tackle my stress. Don’t get me wrong — I hated every freaking minute of it with a fiery, burning passion… but that misery was temporary. Never addressing the problem, however, was permanent.

This might seem obvious to you (like, hello Sam, you’re how old and just now getting this?), but when we’re in the midst of it, we don’t always connect the dots.

We might also assume that we’re helpless or powerless despite the circumstances of our lives being very different (read about “learned helplessness theory” at some point, it can be really helpful to know about).

And oftentimes, to notice and break these patterns, we need help — because this stuff is ingrained and most likely exists for a very good reason.

In the past, these patterns might’ve made sense to minimize your immediate stress as much as possible. But I think most of us reach a point when those old tricks start to interfere with the longer term stability we’re trying to achieve.

Learning more about these patterns, then, is what can help us start to unlearn them. And honestly? Every single person on the planet could benefit from working on that.

Yes, this is all easier said than done. But that’s why it’s a process!

Remember, the stuff on this list is meant to give you a sense of direction as you work towards mental wellness. They aren’t destinations or achievements — they’re simply part of a larger process that some of us call “personal growth” and others simply call “life.”

It’s ongoing, but in therapy especially, it’s always good to set up some goalposts where you can.

My goalpost of “be happy” wasn’t working for me. But the moment I stopped expecting myself to be happy all the time, my life got a whole lot better (and calmer, really) in ways I didn’t expect. Things like purpose, growth, intimacy, and resilience made a bigger impact than “happiness” ever could.

We live in a world in which happiness is fleeting. It comes and goes. But the good news is, we can have meaningful lives — lives in which we grow and connect with others in meaningful ways — without being constantly happy.

Besides… no one needs that kind of pressure!

When we start thinking about happiness as the awesome byproduct of personal growth, rather than making happiness itself the goal that we chase, we wind up with a much stronger foundation for mental health.

And weirdly enough, when we’re not obsessed with happiness and so terrified of losing it, it becomes a lot easier to be happy — and appreciate it, too — than it ever was before.

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Yes, I have a ‘mental disorder.’ But it’s not being transgender.

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It seems like every other week, some conservative with a podcast and an ax to grind announces that being transgender is a mental disorder — despite having no credentials that would actually, I don’t know, make them qualified to diagnose someone.

And I’ll be honest — it’s frustrating to still hear this.

You don’t have to look very far to get the general medical consensus. The World Health Organization and American Psychiatric Association have both affirmed that being transgender is not, in fact, a mental illness.

And while “gender dysphoria” can be medically diagnosed, this is specifically done to access gender-affirming care — not because being transgender is in itself a disorder.

It’s true that some people really and truly don’t get it. There are some folks that use this kind of language because they don’t know how else to talk about the trans experience.

They don’t know exactly what a “mental disorder” is or what it’s like to be transgender. And they see that we’re suffering and dysphoric — so they don’t know how else to talk about it.

As someone who lives with obsessive-compulsive disorder (OCD) and also happens to be transgender, I can tell you upfront that there’s just no comparison.

Being transgender and having a psychiatric illness aren’t at all the same. Comparing them isn’t just an “apples to oranges” situation — metaphorically speaking, we’re not even in the same food group here.

And why is that? To start, let’s talk about what mental illness is.

The American Psychiatric Association defines mental illness as a health condition that impacts thinking, emotion, and/or behavior in a way that creates distress. More often than not, this leads to difficulty functioning in social, work, and/or family activities.

For people who aren’t transgender, they might look at this definition and come to the conclusion that trans people are mentally ill, because many of us do experience distress, and being transgender absolutely does impact how we think about ourselves and how we behave.

The problem is, it’s not being transgender that, in and of itself, creates distress and dysfunction. It’s the difficulty in trying to be who you are when the society around you is deeply hostile towards you.

It’s not my gender identity that’s caused me distress. It’s moving through the world as a trans person.

If anything, identifying this way has brought me enormous relief and made me a happier person overall.

I started to experience distress because of how others treated me. I was distressed when I experienced invalidation, harassment, and rejection. I was distressed when I was closeted, trying to be something that I wasn’t.

And my functioning was impacted when I couldn’t access care, like hormones and surgery.

When I wasn’t able to be who I was, and when I encountered violence and opposition because of it, that’s when I was distressed.

When someone is suffering as a result of how the outside world treats them, especially when they are part of a group that has historically been marginalized, that’s not a mental disorder.

The word you’re looking for there is “discrimination.”

The more “insane” thing to do would’ve been to keep pretending to be someone I wasn’t, which was a much more agonizing experience for me.

Figuring out my gender wasn’t a problem. In fact, it was a huge relief and it improved my life, so long as society did not interfere with my ability to transition. I’m far more mentally healthy now than I ever was prior to transition… by a long shot.

And that’s why I consider my experiences with obsessive-compulsive disorder and my transgender identity to be — categorically — two very different things.

It’s true that how society treats me because of my OCD, and a lack of accessibility to the therapies and medications I needed to thrive, were both contributing to my distress. Discrimination happens to people with mental illness, too, and it can have a profound impact on our lives.

But there’s a component to my distress that originates outside of that mistreatment.

OCD — and the neurobiology behind it — creates patterns of thought, emotions, and behaviors that are in themselves distressing, even under the very best circumstances.

Labeling those patterns as a disorder is the quickest way to say, “There are aspects of my biology and brain chemistry — mixed in with my environment and genetics and everything that makes me a human — that create specific and unpleasant mental/emotional experiences for me.”

Those patterns have been studied over the years, and they’ve been observed in many people who all respond similarly to particular solutions. The label exists to guide people like myself to the resources and solutions that will help reduce our suffering.

Many of these mental and emotional patterns associated with OCD feel at odds with who I am, and when I don’t work to mitigate their impact, my mental health worsens.

Being transgender, though, feels in alignment with who I am, and when I am able to freely explore and express this part of myself, my mental health improves.

The unpleasant experiences that stem from OCD aren’t reflective of who I understand myself to be; I feel more “myself” in the absence of those experiences.

As a transgender person, though, I feel more “myself” when I am able to embrace my gender identity. The more present I am in that experience, and the safer I feel in expressing that, the more whole I feel.

To call my transgender identity “disordered” implies that I need to minimize this part of my experience, but to be the very best (and healthiest) version of myself? I need the exact opposite.

The key differences here, then, are where that distress is coming from, and under what circumstances it improves.

Those two factors are where being transgender and being mentally ill diverge completely.

I don’t experience distress when I think about being a gender other than what I was assigned at birth, and I don’t experience distress from behaving accordingly. In fact, the more freely I am able to live my life in ways that align with my identity, the healthier I am.

But I do experience distress when I think, behave, and feel things as a result of the neurobiology we call “obsessive-compulsive disorder.” And the more I’m able to minimize and manage the impact of those thoughts, behaviors, and emotions, the healthier I become.

In that way, these are totally opposite scenarios.

When we diagnose someone, we’re essentially saying, “This pattern is present, but if it were less so, this person’s mental health would improve.”

So when you say that being transgender is a mental illness, you’re saying that suppressing or minimizing that identity would then lead to mental health.

But this simply isn’t the case. When trans people are able to be themselves and access gender-affirming care, their mental health outcomes are often better. This is especially true in situations where discrimination or violence is less likely, or in the case of youth, when they are supported by their families.

So by its very nature, being trans cannot be a mental illness — because invalidating and minimizing a trans person’s identity has not been proven to positively affect their wellbeing.

It’s the complete opposite.

If you were to classify being transgender as a mental illness, then, you would be making a recommendation to a clinician to treat us in a way that would not improve our health, which completely defeats the point of making any diagnosis in the first place.

But there are plenty of trans people who continually emphasize how much these attitudes harm us.

We don’t need transgender people to stop being trans, nor do we need to further stigmatize our identities and experiences. Gender diversity is not an illness — a society that is hostile towards it, though, is far more distressing.

If diagnoses are meant to help improve a person’s health, I’m still waiting to see any proof that labelling us mentally ill is actually improving our lives.

The sad reality is, many of the people who still insist that being transgender is a “disorder” don’t actually care about our mental health.

Because let’s be honest, if they did? They’d stop talking and do a much better job of listening.

People who are determined to label transgender people “mentally ill” — those who do so to rile people up on Twitter, not just because they haven’t thought about this much — do so because it’s a way of dehumanizing us.

It’s a way of suggesting that we are delusional and that we aren’t who we say we are. It implies that trans people need to be “cured” or “fixed,” and that we shouldn’t exist. To them, we’re mistakes that never should have happened.

That mentality is used to justify a lot of the emotional and physical violence that wounds and even kills us, and it perpetuates the hostility and self-hatred that drives so many of us to suicide.

But I want to be crystal clear about something: my being transgender was never a mistake.

My path hasn’t been an easy one in a lot of respects. But the strength and determination that I carry in my heart is part of a legacy — it comes from generations of transgender and gender nonconforming people, those who were willing to risk everything for a future they knew they might never see.

They stared down all of the dangers that came with that, showing up for each other and for a better world, so that one day, trans people like me could truly live. It’s a legacy that I now have the privilege of inheriting, and it’s one that I don’t take for granted.

For me, being transgender is an honor — and every single day, I step into my life knowing that from the moment I was born, I arrived with a purpose.

I want a future where every trans person can become who they are with every ounce of safety, love, and affirmation they deserve. And if that’s your definition of “crazy,” it sounds like I have my work cut out for me.

Challenge accepted.

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Transgender people shouldn’t have to lie about their mental health. But many do.

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Until this last year, accessing top surgery was a losing battle for me. But it’s not because of where I live, my health insurance, or any of the other typical barriers you might imagine when trans people are looking for care.

It’s because I’m mentally ill.

I live with obsessive-compulsive disorder (OCD) and complex trauma; I’m also transgender. And I’ve found that, at this particular intersection, accessing the health care I need has been an uphill battle.

I’ve been denied care numerous times over the years, under the premise that I was too mentally ill to undergo a major surgery — ignoring that gender dysphoria, an acutely painful experience for many trans people, was contributing to my poor mental health.

It took two years to be placed on a waitlist for surgery, when a therapist finally decided that I was “stable” enough (without any explanation of what that actually means).

And it wasn’t just surgery that was made difficult. Psychiatrists in the past have encouraged me to stop taking testosterone, convinced it was making me “worse.” While hospitalized for depression, I had nurses trying to withhold my hormones because they didn’t feel it was “necessary.”

This last January, I finally got top surgery and I now have consistent access to hormone replacement therapy. But I still live in fear that, should my mental health decline again, I won’t have access to the gender-affirming care that has vastly improved my life and wellbeing.

Frustrated by my own experiences, I started reaching out to other trans people with mental illness to see if they’d encountered similar challenges — and I was horrified by what I found.

“A lot of doctors I saw questioned my ability to handle hormones as someone with a history of depression and self-harm,” Luke, a non-binary trans man in Ontario shared with me.

Could that history really justify someone being denied hormones altogether? I was wondering that, too. So I did a little research on the literature we have. And… it’s not exactly helpful, to say the least.

The World Professional Association for Transgender Health (WPATH) created their Standards of Care. The SOC are, more or less, the most recognized clinical guidelines for treating transgender patients. They advocate for an “informed consent” model: allowing for trans people, once fully informed of the risks and benefits of treatment, to choose for themselves the right path forward.

The standards also advocate for competent treatment of co-existing mental health conditions with the use of therapy and medications, where appropriate.

But if you look closer, you’ll find that they are limited in how they discuss treatment of mentally ill trans people. “Clients should be assessed for their ability to provide educated and informed consent for medical treatments,” it reads, without actually offering adequate guidelines for what this looks like in practice.

It also states that, before surgery is considered for someone with severe psychiatric disorders and impaired reality testing (so delusions or hallucinations, really), “an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated.”

This raises a really important question: How, exactly, do we measure “improvement” in mentally ill trans people?

And if there isn’t significant enough improvement, is a trans person simply in limbo, unable to access transition-related care?

Mentally ill trans people, then, are ultimately left to the whims of whatever mental health clinician they happen to be seeing — with very little recourse if they disagree with that clinician’s assessment of their readiness for care.

The SOC directly list conditions like psychosis, bipolar disorder, dissociative identity disorder, and borderline personality disorder as mental illnesses that could impact “readiness for surgery.”

But in a document of 120 pages, the SOC actually say very little on how, exactly, to assess at what point a mentally ill trans person might be “ready” to access surgery. Until this is made clearer, transgender people are put in an impossible position of deciding whether or not it’s safe to disclose their mental health status.

Interestingly, WPATH — and the overwhelming majority of care providers who work with transgender people — agrees that gender-affirming care is medically necessary. What’s puzzling is that, in almost any other context, mental health status would not preclude someone from medically-necessary care for any other condition.

Gender-affirming care somehow seems to be an exception, reinforcing the notion that trans-related care is “optional.”

The most direct mention of denying access to surgery in the Standards of Care reads, “No surgery should be performed while a patient is actively psychotic.”

This seems to be the only statement that a trans person can point to when they encounter obstacles, but given the other mentions of “readiness” and “improvement,” there are still too many ambiguities— and too many clinicians who aren’t at all familiar with the SOC to begin with.

Not to mention, none of this helps trans people with more severe mental health challenges who still need to access care.

It’s worth noting, too, that disorders like borderline personality disorder — which is flagged as a potential issue in the SOC — include an “unstable sense of self” as a diagnostic criteria, as well as difficulty trusting others and recurrent suicidality.

Coincidentally, these sound an awful lot like issues any trans person could struggle with simply because they are transgender.

In other words? Any trans person could  be denied care if a clinician who’s unfamiliar with this population misdiagnoses them. In fact, at the time at which I was denied surgery, I myself was misdiagnosed as borderline. When that diagnosis no longer applied, I finally found myself on the waitlist.

While some boundaries surely need to exist, the utter lack of clarity in these guidelines means that trans people with any mental health struggle are at risk.

I spoke to Traci Lowenthal, a licensed psychologist that has worked closely with the transgender community. Most of the time, she shared, “mental illness should not be a barrier to getting necessary trans health care.”

The keyword here being, of course, “should.”

When assessing the readiness of a mentally ill trans person to pursue surgery, the most important factors, she says, are safety and the ability to consent.

So long as they can provide informed consent and keep themselves safe (the example she gives is proper hygiene and medication compliance post-surgery), there should be no barrier in accessing gender-affirming care.

“If a person has delusions,” she continued, “it would be ideal if their mental health provider could help them prepare for how those delusions may impact them while they receive medical care and during recovery.”

Compare this to my two-year battle to access surgery. It wasn’t because I was delusional — I was told, in essence, that I was too depressed to undergo surgery. There was no effort made to determine if surgery might improve that depression, and if there could be ways to better prepare for surgery in that state of mind.

The end result? Transgender people are scared to be honest about their mental health. And this has serious consequences.

I spoke with Ghost (a pseudonym), a trans person in Detroit, Michigan, who experiences schizoaffective disorder, delusions, and anxiety. For them, this has meant a constant fear of interference and mistrust in clinicians. “I am absolutely terrified that my mental health status will be used against me [in transitioning],” they explained.

“I’ve already experienced ‘the look’ from a medical professional,” they went on. “The one they use when you tell them [your mental health status], and they’re suddenly very skeptical of you.”

And with disorders like schizophrenia and borderline disorder especially, all of the trans folks I spoke to said they encountered disbelief when disclosing they were transgender, simply because they had one of these illnesses.

Some trans people have resorted to hiding their mental health history, or outright lying about their mental health status to providers. Others postponed psychiatric treatment altogether to ensure they could first transition without interference, which included forgoing psychotropic medications they desperately needed.

The unfortunate reality is, clinicians can’t adequately prepare someone for the specific challenges of medical transition if they don’t know about their client’s mental health status. And of course, when trans people have greater reluctance to seek out psychiatric care during their transition, they’re unlikely to get the support they need for the best possible outcome.

The fact that trans people should have to choose between gender-affirming care OR mental health care is unjust. Access to both is critical, especially for such a vulnerable population.

Trans people face an extraordinary risk for suicide — but if they fear disclosing their mental health struggles, they are likely to suffer in silence. This puts their lives in danger.

And when a trans person with mental illness is, indeed, denied access to care, the path forward is equally unclear.

Florence Ashley, transfeminine activist and LL.M. candidate at McGill University — with a special focus on bioethics and transgender health care policy — highlights just how much of a grey area this is.

Pointing again to the WPATH Standards of Care, she notes, “The only case that WPATH describes as precluding surgery is while the patient is ‘actively psychotic.’”

The rest, she agrees, is murky at best. “As with many issues faced by trans people, the best we can do is extrapolate from sources of law that have yet to be applied to the specific issue,” Ashley said, noting that a case might be made on the grounds of medical liability and professional ethics.

However, there appears to be no legal precedent for trans people specifically to look to when making such a case.

“This really ties back to a core problem in trans law,” she continues. “At some point, policymaking bodies will have to take up responsibility and pass enforceable policies and laws on trans-specific problems in collaboration with trans communities. Otherwise, we’re always going to be left behind.”

It’s evident, then, that more research and attention is needed to properly support trans people with mental health struggles. We need clearer guidelines, direct policies, and competent clinicians who are prepared to work with trans people regardless of mental health status.

For the transgender people who fear that they will not be able to access gender-affirming care, however, this offers very little comfort.

“I’m constantly worrying that someone will look more deeply into my history and see attempts, hospitalizations, a history of self-harm, and take it all away,” Tamsin, trans woman in Vancouver confessed.

While she finally has access to hormones, she fears it isn’t guaranteed. “[It will] cause me at least some anxiety for life.”

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10 Ways to ‘Reach Out’ When You’re Struggling With Your Mental Health

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I’m a mental health writer and advocate, and a suicide attempt survivor. I’ve told people on this blog many times, “Keep reaching out.” I’ve written multiple articles preaching the importance of vulnerability, defying stigma, and owning your struggles.

This is my whole thing, okay? This is what I do.

So when one of my closest friends died by suicide a few weeks ago, I wasn’t just shocked — I was completely gutted.

I thought there was never a question of whether or not my loved ones could reach out to me. But the very person who I’d talked to so often about mental health… didn’t call me.

Not even to say goodbye.

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The last night I spent with them.

In the weeks following their suicide, my grief took me to dark places. I soon began having my own suicidal thoughts. And even then, when it was my turn to “reach out”? Even after losing my friend? I began to withdraw, too.

I watched, with painful awareness, as I did much of what my friend seemed to do leading up to their suicide. I wrote myself off as a burden. I isolated myself. I got lost in my own head. And despite knowing the danger of where I found myself, I said nothing.

After an especially scary night, I realized something: No one ever explained to me how to ask for help. No one told me what “reaching out” even meant.

As my grief began to snowball, I hesitated to tell anyone I was struggling, largely because I didn’t know how. I didn’t know what to ask for, and without knowing what to ask for, it felt too complicated and futile to ask.

“Why didn’t they tell me?” is such a common refrain when we talk about suicide or mental health challenges in general. It’s easy to make this remark, because “tell someone” seems like a simple request. But in truth, it’s vague at best.

“Reaching out” is this skill we’re somehow expected to know, yet it’s never taught and rarely modeled for us.

It’s this vague, hopeful sentiment that people throw around, without ever really defining it. What are we asking people to do or say? It’s not exactly clear.

So I want to get more specific. We need to be more specific.

I don’t know if an article like this could’ve saved my friend. But what I do know is that we need to normalize asking for help and talk about what that might look like, rather than pretending it’s a simple and intuitive thing to do.

Maybe then, we can reach people sooner. We can meet them more compassionately. And we can find better ways to support them.

So if you’re struggling but you don’t know what to say? I get it.

Let’s talk about it.

1. “I’m (depressed/anxious/suicidal). I’m not sure what to ask for, but I don’t want to be alone right now.”

Sometimes we don’t know exactly what we need, or we’re unsure of what someone can offer. That’s okay; that shouldn’t discourage us from reaching out. It’s perfectly fine if you have no idea what you need or want — especially when all you can think about is how much you’re hurting.

Let someone know how you’re feeling. You might be surprised by the ways they offer to support you. And if they aren’t helpful? Keep asking until you find someone who is, or seek out a hotline (I know it can be weird to talk to a stranger, but there are some awesome hotlines out there).

2. “I’m struggling with my mental health and what I’ve been trying isn’t working. Can we (meet up/Skype/etc) on (date) and come up with a better plan?”

Feeling helpless or exhausted is part and parcel for dealing with a broken mental health system. But a team approach can make it a little more manageable. Sometimes we need a cheerleader/researcher that helps us explore our options, especially when we’re having trouble believing that we have any.

One thing you’ll also notice is that, for almost everything on this list, I suggest setting a time.

This is important for a couple reasons. The first being that it helps the person you’re talking to understand the urgency behind your ask. It can also be helpful to know that there’s an event in the near future when you can expect to receive some support. This can help us hang in there when things get bleak.

3. “I don’t feel safe by myself right now. Can you stay on the phone with me/come over until I calm down?”

I know this is a hard one to say. Because we often fear telling someone just how much we’re struggling, and admitting that we don’t feel safe? That’s a biggie. Obviously you can replace the word “safe” if it’s not working for you, but I always encourage people to be direct, because it’s the surest route to getting exactly what we need.

Asking someone to be present might feel especially vulnerable. It might not even feel like, in the moment, it’ll make that much of a difference. But you’re more likely to feel better with support than without any.

And remember, from everything we know about mental illness, depression is more likely to be a liar than a truth-teller (I talk about that a bunch in this blog post).

4. “I’m in a bad place, but I’m not ready to talk about it. Can you help me distract myself?”

You do not have to talk about what’s bothering you if you’re not ready.

Opening up a whole can of worms might not be the safest or best thing for you in that particular moment. And guess what? You can still reach out for help.

Sometimes we just need someone to shoot the shit with, so we aren’t stuck in our heads, making ourselves a little crazy. This is a valid and healthy thing to ask for! And it’s a subtle way of making folks aware that you’re having a rough time, without needing to go into detail.

The sooner the folks around you are aware that you’re having a hard time, the quicker they can show up to help you through it.

Early interventions are so critical for our mental health. In other words: Don’t wait for your whole basement to flood before you fix a leaky pipe — fix the pipe when you notice the problem has started.

5. “Can you check in with me (on date/every day), just to make sure I’m alright?”

I cannot say it enough — do not underestimate the value of asking for a check-in. I am such a huge fan of this as a coping skill, especially because it can be super helpful for everyone involved.

If you take nothing else away from this article, it should be this: Please ask people to check in with you. It’s such a small thing to ask for in the age of texting, but it can help us stay connected, which is freaking critical for our mental health.

(If you’ve played The Sims before, remember the social bar? That’s you. You need to fill it. Humans need to connect with other humans. It’s not just about wanting to, it’s that we actually require it to survive.)

And this can happen in so many smart ways. A few of my favorites:

  • “I haven’t been doing well. Can you text me every morning to make sure I’m okay? It would really help me.”
  • “Hey friend. I’ve been kind of sad lately — do you maybe want to Snapchat/send selfies to each other before bed every night, just to check in? It’d be nice to see your face.”
  • “I’m in a funk right now. Do you want to be self-care buddies? Like text each other once a day something that we did to care for ourselves?”
  • “I’ve been isolating myself a little lately. Can you check in with me every so often, just to make sure I didn’t fall off the face of the earth?”

Add emojis wherever fitting if you want it to feel more casual (but really, you don’t need to, there’s nothing wrong with asking for what you need!).

Asking for people to check in with you when you’re struggling is just like buckling your seatbelt when you get in a car. It’s just one extra safety measure in case things get rough.

Both can actually save lives, too. Consider this a PSA.

6. “I’m having a hard time taking care of myself. I need extra support right now around (task). Can you help?”

Maybe you need help getting to an appointment or the grocery store. Maybe you need a cheerleader to make sure you took your meds, or someone to send a selfie to to prove you got out of bed that morning. Are your dishes piling up in the sink? Do you need a study buddy? It doesn’t hurt to ask for support around tasks like these.

Sometimes these things add up when we’re struggling with our mental health. But we forget that it’s okay to ask for a hand, especially at those times when it could really make a difference.

Being an adult is already challenging. If you’re going through a rough time? It’s even harder. We all hit a point when we need some extra support. Don’t be afraid to let folks know directly how they could support you.

7. “I’ve been feeling so low. Can you remind me about what I mean to you or share a favorite memory? It would really help me.”

I used to think that asking for something like this meant I was “fishing for compliments.” And what a lousy way of looking at it…

Sometimes we need reminders that we matter! Sometimes we can’t recall the good times, and need someone to help us remember them. This is true of every single human being on the planet.

It’s such a simple request, too. If you’re the kind of person that feels nervous about making a big ask (again, I’d encourage you to challenge that assumption — it’s okay to ask for help!), this can be a small step in the right direction.

8. “I’m struggling right now and I’m afraid I’m reaching my limit. Can I give you a call tonight?”

To be honest, it wasn’t until my friend died that I finally found these words in particular.

Up until that point, I’d never been sure exactly how to raise the alarm. You know, that moment when you’re not at the end of your rope, but you’re getting there? It’s a crucial moment.

Yes, you can and you absolutely should reach out then, even if you aren’t sure if it might make a difference (spoiler alert, people might actually surprise you). I think about how much pain I could’ve avoided if I’d saw that moment for the opportunity it really was.

Listen to that little voice in the back of your mind, the one that’s trying to tell you that you’re a little too close to the edge for comfort. Listen to that nagging feeling that tells you you’re in over your head. That’s your survival instinct — and it’s an instinct you should trust.

9. “I know we don’t talk much, but I’m going through a tough time and I feel like you’re someone I can trust. Are you free to talk (day/time)?”

I wanted to include this because I realize that not all of us have people we’re close to that we confide in.

When I was a teenager, everything changed for me when I reached out to a teacher at my high school that I barely knew. She had always been incredibly kind to me, and I had a gut feeling that she would “get it.” And she did!

To this day, I still believe that she saved my life at a time when I had no one else to turn to. She connected me with a social worker, who was then able to help me access the resources I needed to recover.

While it’s important to be respectful of people’s capacities and boundaries (and be prepared, of course, if someone can’t be there for you or isn’t helpful — it’s not personal!), you might be surprised by the responses that you get.

10. “I’m suicidal. I need help right now.”

Raise the alarm.

Raise the damn alarm, friends, and be as direct as you need to be. An emergency is an emergency, whether it’s a heart attack or a self-harm risk. Harm to you in any form is reason enough to ask for help.

I promise you, there’s someone in this world — an old friend or a future one, a family member, a therapist, even a volunteer on a hotline — who wants you to stay.

Find that person (or people), even if it takes time. Even if you have to keep asking.

Give people the chance to help you. It’s a chance that my friend deserved, and it’s a chance that you deserve.

(And if all else fails, I have this resource about going to the emergency room when you’re suicidal. I’ve personally been hospitalized twice, and while it’s not a ritzy vacation, it’s the reason I’m here today.)

Pick something from this list. Write it down, even if it’s on your hand or a sticky note. Reach out — because now you know how.

Hell, bookmark this article while you’re at it. I know I’m going to, because there are times when I need this advice, too.

If you’re struggling with your mental health, let me remind you that it’s never too soon or too late to let someone know.

And it’s never, ever too heavy, too messy, or too much to ask — even if you asked fifty times the day before.

I’d have rather had my friend “bother me” every day for the rest of my life than have to lose them forever. Their life was that precious.

And yes, so is yours.

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Hey there, friend. Before you go, I want to share some resources with you.

If you’re suicidal, call the National Suicide Prevention Lifeline at 1-800-273-8255, the Trevor Project at 1-866-488-7386, or reach the Crisis Text Line by texting “START” to 741741.

You can also go to the emergency room. If you’re not sure if you should or how to prepare for something like that, I’ve got an article for that, too.

This isn’t just a generic “here are some numbers” plug, this is a “I want you to stay, we need you here, please don’t go just yet” plea.

 

Screenshot 2018-03-03 at 10.35.49 AMAnd lastly…

There’s a memorial fundraiser in honor of my dear friend, Cris Alvaro. The funds raised will go to organizations that support trans mental health and racial justice.

This article is, of course, dedicated to them.

Topher, you’re still the brightest star in my galaxy. We couldn’t keep you safe. But I will never stop fighting for a world that could have.

 

Feature photo by Matthew Henry on Unsplash.