How One LGBTQ Clinic Practices Trauma-Focused Therapy
Ample research shows that trauma and HIV are intimately linked. Past traumatic experiences, such as physical or sexual abuse -- or family/societal rejection of one's sexual or gender identity -- put people at higher risk of HIV, and people with HIV generally have higher rates of trauma than in the general population. The repercussions can include increased depression, anxiety, and substance use, as well as lower HIV medication adherence, poorer health, and worse longevity.
That's why it's so important that therapists and other mental health providers serving people with HIV understand that trauma can be a huge part of their story -- and incorporate that into treatment. Increasingly, and not just for clients with HIV, mental health providers offer trauma-focused therapy (TFT) that helps clients pinpoint and process past (episodic or chronic) trauma in their lives and develop practical ways to minimize its impact going forward.
In New York City, the LGBTQ-serving Callen-Lorde Community Health Center, which treats many clients living with or at risk for HIV, is one such provider. We chatted with Morris Roy, Ph.D., clinical psychologist and manager of behavioral health at Callen-Lorde, to learn exactly how TFT works.
Tim Murphy: Hi, Morris. Thanks for talking with us. So, introduce us to TFT.
Morris Roy: Well, I've been doing TFT for 12 years. It's a subcategory under cognitive-based therapy (CBT) that is very structured. There are four modules: mindfulness/awareness, which is stopping and looking at your inner state; distress tolerance; emotion regulation; and interpersonal communication. It's to give you a smorgasbord of concrete skills.
TM: What do you mean by emotional regulation?
MR: A lot of people with trauma get disregulated and need to talk themselves down. How do you take care of yourself emotionally? Rest your mind? Learning how to do this is very concrete, and people seem to find it very soothing and effective.
TM: So what is trauma exactly? How do you define it?
MR: Chronic trauma is much more pervasive and common than episode-based trauma, such as having been involved in one very violent incident. A lot of the transgender people I work with experience the chronic trauma of people snickering about them in public, being told, "You're really a man" or "You're fooling people," or being denied their gender identity at various health or other offices. When that's a one-time thing, people might be able to let it roll off their back, but when it's happening routinely, it can lead to agorophobia [fear of being outside] or panic attacks. It can be hard to work with in therapy, because it's not something people are imagining. And it's also connected to danger. People read in the news about other transgender people being beaten or killed, so when they are harassed, it triggers: "Am I going to get killed?" And I'm talking about daily life for trans people in New York City. In other areas, it can be even worse.
TM: What other clients have a lot of trauma?
MR: All LGBTQ clients have more trauma than the general population. It could come from lack of family acceptance. Very few of our patients had that and must create "families of choice" to be resilient. And clients living with HIV can have trauma from the HIV diagnosis itself, or often from rejection from sexual or romantic partners once they tell them they are HIV positive.
TM: What are the symptoms of trauma?
MR: People say they're having flashbacks to certain events. Trauma is unprocessed memories that are not woven into the narrative of the person's life. They're stand-alones that come back at unwanted times. So the purpose of therapy is to integrate the trauma into the person's life narrative, but in a non-traumatizing way.
MR: First you have to develop a good relationship with your client, have a good alliance, and be caring and sincere. I tell my clients that this is my job but it's also a relationship. Then people have to understand that when they are talking about their trauma, they are in the driver's seat. They can't feel like a train going down the track that has to continue with the story when it gets too painful. So if a session is 45 minutes, we'll stop 15 minutes before the end so they have time to compose themselves.
TM: So how do you integrate the traumatic memories into the life narrative?
MR: People will describe the traumatic situation as if it's a news report, with no emotional connection. You have to describe it viscerally. So if someone was in a car accident and they simply say "we crashed," I ask them to describe smells, which for whatever reason are highly emotional and bring people back into that moment, what they were feeling. But all this has to be done slowly and under the person's control. I say, "Take me back into that memory and describe it, but when you feel like you're no longer in control or it's getting too uncomfortable, stop." The point is to have the person control the memory rather than the memory controlling them. And part of the process is to put the memory in context so that it doesn't define them. It's one story in their life of many stories.
You can also use EMDR, eye movement desensitization and reprocessing. As the person is talking about the trauma, you're tapping on their legs bilaterally so you're connecting the two sides of the brain, the emotional and rational thinking about the traumatic issue.
TM: Can you give an example of a client?
MR: Yes, I'm thinking of a transgender female client who is constantly being called names on the street, having her wig pulled off, being threatened [with violence]. These are traumas. It took time for her to open up and feel safe with me. But eventually, she said it was very helpful to be able to come in once a week for 45 minutes and tell these stories to someone who was listening without judgment and not saying, as often happens in her personal life, "Get tougher," or "Get over it." That's super invalidating and hurtful.
TM: Did she learn tools to help with her trauma?
MR: One tool is to not catastrophize, to realize that just because you wake up from a bad dream or see on the news that someone was attacked, to not take it as an omen that it will happen to you. But to look at the statistical evidence and talk yourself down.
TM: Yes, but we know it is a reality that transgender and more broadly LGBTQ people are attacked.
MR: It's true, and people internalize the hatred. So one thing that is helpful is to remind people that being trans, gay, etc., was not a choice. It's their essence. And that's super helpful, to keep redirecting people to the idea that you're entitled to be in this world who you were born to be.
TM: So what are the outcomes we are looking for from TFT?
MR: One is to be able to identify triggers for emotional disregulation or self-harm behaviors and avoid them by using skills. One simple skill is internalizing the idea that everything passes. People in a really bad moment can't imagine it passing. But for many of my clients, just holding the thought, "This too shall pass" can be life-changing. The most important take-away is: Don't give up, and don't blame yourself.
TM: So, you are cisgender. Does the therapist have to match the client, either in terms of gender or sexual identity, race, etc.?
MR: It depends. This is a big question in therapy. Sometimes the person would do better with someone with a matching demographic, and sometimes not. You often hear people say, "I was looking for a gay therapist but found someone who was not, but we found other things in common." It's difficult to describe exactly how two people bond. Here at Callen-Lorde, if someone asks for a certain kind of therapist, we'll try to honor that.
TM: Where can people go to learn more about TFT?
MR: Skills Training Manual for Treating Borderline Personality Disorder by Marsha M. Linehan is very accessible and has lessons in it with skills of how to get through a bad day and regulate one's emotions. [Therapy techniques for TFT and borderline personality disorder overlap.] Psychology Today can help you find a therapist, and, more and more, therapists are working with Skype and even FaceTime if someone is in a rural area.
TM: Thank you for talking!
Editor's Note: If you think you need mental health care, talk to your primary-care provider or use the HIV services locator. If you are in extreme distress or feeling suicidal, call the Suicide Prevention Lifeline.