Masters in Practice: LGBTQ+ Mental Health and DBT w/ Dr. Kiki Fehling

Most therapists overlook one of the most powerful tools for supporting LGBTQ+ clients: the deep connection between minority stress, emotional validation, and joy. In this eye-opening conversation, Dr. Kiki Fehling—an expert in queer-affirmative DBT—shares how understanding the unique challenges faced by queer individuals can transform therapy from mere coping to building a genuinely fulfilling life.

Discover how minority stress operates like chronic invalidation, fueling mental health difficulties like anxiety, depression, and trauma. Kiki reveals how DBT’s biosocial model not only helps clients manage emotions but also reframes their experiences—empowering clients to see their identities not as sources of pathology but as sources of strength and joy. She explains how the foundational CBT skill of opposite action can combat shame and anxiety, leading clients to actively pursue moments of queer joy—whether through celebrations, community, or self-affirmation.

You'll learn practical ways clinicians can avoid microaggressions—like making assumptions about pronouns or relationships—and how to repair ruptures that threaten trust. The episode emphasizes the importance of fostering therapy spaces where queer clients can fully embrace their identities, find happiness, and counteract societal stigma. Whether you're a mental health professional or a queer advocate, this conversation offers a clear map for integrating affirming practices that lead to genuine resilience and happiness.

Filled with actionable exercises from Kiki’s new workbook, along with her insights on cultural humility and self-work, this episode is a must-listen for anyone committed to supporting LGBTQ+ folks in living their fullest, happiest lives. Queer joy isn’t just a moment—it’s a vital component of mental health and belonging.

Her New Book: https://www.kikifehling.com/lgbtqworkbook

Therapist Guide: https://www.amazon.com/dp/0197643302?lv=shuf&channelId=500&plpRedirect=mhFallback

Free worksheets/handout: https://www.newharbinger.com/9781648486623/the-lgbtq-mental-health-workbook/

Find a LGBTQ+ community center near you: https://www.lgbtqcenters.org/

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To hear more and stay up to date with Paul Wagner, MS, LPC and Ray Christner, Psy.D., NCSP, ABPP visit our website at: 

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“Be well, and stay psyched"

Transcript

SPEAKER_01 1:20

Hello and welcome to the Psych2Practice Podcast, your one-stop for practical and useful clinical information, masterful insights from experts in the field, and a guide to daily living. I'm your host, Paul Wagner. And while Ray isn't able to join me today, I was still able to have a phenomenal conversation with Dr. Kiki Failing, and we were going over her new book, The LGBTQ Mental Health Workbook. And while and Kiki actually is coming from us, uh, you know, she reached out to the show from a previous DBT episode that we did, and it was really wonderful to connect with her and really kind of taking the concepts really refined in DBT and being able to talk about what that looks like when working with queer clients and continuing uh, as you'll hear in the episode, promoting this cultivation of queer joy for our queer clients. Um, for those of you who aren't familiar with Dr. Kiki Failing, she's a licensed psychologist, author, and Lenahan board certified expert in DBT, who's passionate about making evidence-based mental health information more accessible. Kiki focuses on advocacy and public education around emotion dysregulation, suicide prevention, and LGBTQ IA Plus mental health. To this end, Kiki shares resources on social media for over 80,000 followers, writes the How to Queer Joy newsletter on Substacks and is the author of the LGBTQ Plus mental health workbook, self-directed DBT skills and DBT Cards for Coping Skills. And you know, for those of you at home who are listening, you know, we uh oftentimes I think as clinicians, what really need good resources for ourselves is really needing good resources that we can recommend for our clients. And um, after having read through the book, um, I think it's a phenomenal kind of does a great job of both. While not intended to be specifically a clinician resource, uh, it is a self-help book for those individuals who are really potentially suffering or struggling with minority stress related to LGBTQ uh experiences. And I think the book does a great job of helping to support them. And I as a clinician, being able to read it, was really able to kind of find some wonderful takeaways. And I know that there's some uh concepts that the book talks through as well as just some exercises and worksheets that it has that I know I'm gonna be using in sessions. So check the show notes to check the book out. And we hope you enjoy this Masters in Practice episode, LGBTQ plus mental health and dbt. Kiki, thank you so much for joining us today on the Site to Practice podcast. Uh, really excited to have you here.

SPEAKER_00 3:59

I'm really excited to be here. So yeah, thanks for having me.

SPEAKER_01 4:01

Um and well, you're here uh today. We're we're talking a bit about your new book, the LGBTQ Mental Health Workbook. Um, and I just have to say, uh I made a specific note of this. I love the subtitle of it of Find Emotional Resilience, Self-Love and Queer Joy with Dialectical Behavioral Therapy. So I I know when I first picked it up, I was like, I I think I was with my family and I was like, I really love this subtitle. So it's been something that just I I love that it, I think it captures really well the pieces of the book that at least when I was reading through it, that I took away. And so from the beginning it stood out. So um, but excited to talk here. And um, you know, for those of our audience that maybe aren't as familiar with your work, can you tell us a little bit like what brought you into the mental health field or what's what's your origin story here?

SPEAKER_00 4:48

Yeah, totally. So I maybe where it starts, the origin, is I've always felt like a very emotionally sensitive person myself and naturally gravitated to other emotionally sensitive people. And as I was growing up, it was very became pretty obvious pretty early that I wanted to go into some sort of helping field. And then at some point during high school, um, I had a friend die of suicide. And then that was always in the back of my mind as I was going to college and then eventually applying to grad school, of maybe wanting to focus specifically in that area of how can I decrease suffering and specifically help prevent suicide for folks. And for anyone who goes into suicide prevention, then perhaps it's not surprising that I found my way into discovering DBT, dialectical behavior therapy. And I was incredibly lucky to go to Records University for grad school for my PhD, where I got to work with Shereen Risby, who was a direct student of Dr. Marshall Lenahans, as some as Jesse has already talked about on your podcast. Yes. And Shireen, just from the very beginning, brought me into the world of DBT so deeply. And I became a convert really quickly. Just everything of DBT resonated with me. The dialectics, obviously, the concrete skills, the radical genuineness of being a therapist and the room with the client. It just really clicked. And then it helped me personally as a highly sensitive person, learning DBT skills and teaching them to my clients. It in a lot of ways truly was life-changing for coping with the various stressors of grad school and then let alone some personal life stuff that happened during and after grad school. And then while I was in grad school, I also was doing research with my mentor, Dr. Eddie Selby, on suicide and self-harm and understanding what influences those for people on a real life basis. And I specialized my research on LGBTQ. That's partly because I am queer myself and a fairly privileged queer person. And so it felt really important to try to give back to the community and try to create more research for how can we understand LGBTQ people's increased risk for suicide. And then after grad school, I was very lucky to, when I was working in Manhattan at a group practice there, to be able to provide a queer affirmative, comprehensive DBT program for the first time. And again, I was overwhelmed as a queer person, a queer therapist, of how life-changing, queer affirmative DBT could be specifically for my clients, but also for myself. And I'm just so thrilled to be able to talk to you about this topic because I think it's such a good fit in a number of ways. So I would love everyone to kind of know more about how to be queer affirmative, but also how DBT principles and skills might be relevant for them and their clients.

SPEAKER_01 7:48

Absolutely. Well, and it sounds like this is an excellent lead-in to kind of where the inspiration from the book really came in. It sounds like it's really just kind of that natural progression, but I guess wanting to ask a bit more specifically of what was that driving force of uh with writing the book? Um, and again, to call that out, it's the LGBTQ mental health worth workbook available now. So, what was that push there to take it from practice into writing?

SPEAKER_00 8:15

It was probably mostly the personal experience as a therapist working with queer people, but also a queer person doing that work, where I saw the way that my clients, my queer clients knowing that I was queer, that everyone else in the DBT skills group was queer, that this was a safe space, like they would explicitly tell me over and over again that that was really important and helpful for helping them to talk about things that they hadn't felt comfortable talking about in other therapy spaces, and to just have that base understanding and validation around the difficult parts of being LGBTQ in today's world. As I used DBT to help them overcome some of that stigma, condition shame, hypervigilance anxiety of being queer in this world, it helped me also in the process. And it was truly one of the most transformative clinical experiences. Like I walked away, really better understanding how to build my own life worth living, the way we talk about in DBT. And when I had had so many clients, even in New York City, like pretty progressive and liberal, come in saying they'd been to previous therapists who had microaggressed in some way, or they had people in their life that didn't understand them. It became clear to me the ways that obviously we know DBT therapy in general isn't as accessible as we want it to be, but queer, affirmative, evidence-based mental health information, even less so. And so I wanted to write this book in order to make it more available and to share the wisdom that I really say my clients and I found together through that group. So yeah, that was what the book was about.

SPEAKER_01 9:50

And I I just have to say, like after going through the book, um hearing you describe it in that way, I think you really captured all of it. And especially the approachability. And anyone who's listened to our uh our episode with Jesse will know that I I don't have the strongest background with DBT. It's something that I feel aware of, but I don't feel confident enough to kind of go in and certainly not holding my own in like a specific conversation, but being able to, you know, reference it or direct it if it's valuable. And it it took those concepts that you know I was hearing from Jesse and I've heard in other areas, and it really I think did a great job of honing it to, you know, if someone's not familiar with DBT, it's a great introduction as a you know, as a clinician, being able to pick it up and as a resource, so being able to recommend it to clients, but also pulling from some of the exercises, because there is a ton of exercises in the book, and it just uh blends it so well, and I think it makes it really easy to digest. And I think also it takes some of those pieces as a practitioner that I can reference as far as I don't I don't think it was necessarily labeled as this, but I'm like, oh, here's some Socratic questioning elements that I see coming in and seeing the way that it flows through specifically with such an affirming focus there. So again, not only the DBT skills, but you know, as for clinicians that are really wanting to practice and working to be more affirming, being able to take that and really trying to sit with and like identifying that experience. I think you translate it so well in the book.

SPEAKER_00 11:19

Thank you. I really appreciate that. It was a labor of love, so it's always nice to hear that it came off well in that way. Yes. Yeah, I will say, like again, to be really explicit, this book is self-help meant to be used by LGBTQ people themselves. And there are a few chapters in particular, and we'll probably talk about the topics that I'm talking about here as we move forward in the conversation, where the psychoeducation or the framework that I'm providing to the client is very much almost like trying to give them what a therapist would be giving them. And so I think that a therapist reading them could benefit a lot for understanding their queer clients, but also potentially understanding themselves, which I hope we'll get to talk about a little bit, whether or not they're queer, to be clear.

SPEAKER_01 12:03

Yes. And maybe kind of getting into one of those aspects that the book I think really kind of breaks down is being able to view, I guess, viewing this through the lens of minority stress. And I guess can you elaborate a little bit on like what is minority stress and how does that impact individuals uh in the LGBTQ community and their their experience with mental health?

SPEAKER_00 12:24

Yes. So this is one of the things I had in mind that I do think therapists should know when working with LGBTQ clients. So one of the most well-validated theories in queer mental health right now is called the minority stress theory. And it gets at the idea that minority stress are the unique and chronic societal and social stressors that queer and trans people face because they live in a society or culture that stigmatizes those queer and trans identities. So discrimination, stigma, prejudice, biases, microaggressions, these things. And so this can be explicit discrimination, like being called names or being assaulted or being fired, or seeing other queer people experiencing discrimination. But it can also include like internal experiences of minority stress, like just being scared or hyper-vigilant to experience discrimination or internalizing stigma, getting stuck in negative self-judgments about myself, my queerness, about other queer people, and getting stuck in shame related to gender and sexuality. And so these minority stressors, the research shows us that they are very directly related to the mental health disparities that queer people face. So the more minority stress that a queer trans person reports experiencing in their life, the more likely they are to struggle with anxiety, depression, substance use, and other mental health difficulties and suicide, which is what I was studying in my research.

SPEAKER_01 13:56

And again, I think it was probably within the first few chapters of the book really highlighting that and discussing the importance of not viewing, you know, identity as the issue, but it's the experience of the of the discrimination and experience of being, you know, marginalized and you know, in that my being in the minority and stigmatized in the way, and how to adapt and address that. And it's not addressing identity. And so to call that out here, you know, early on, like, you know, in the workbook, um, it is certainly something that is celebrating it again as someone who isn't that target population, you know, as someone who identifies as cishet, like it is something that I try to be very mindful of and being aware of like that. And I think it's really important and valuable to call out that specific of like, no, this is affirming and this is what the focus is there, and this is how the the interventions are going to be tailored and placed there.

SPEAKER_00 14:51

Yeah, thank you for saying that so explicitly. That's exactly why I tried to say it so explicitly up front in the book. Of I mean, first of all, you know, homosexuality used to be a mental disorder in the DSM. Yes. And still today, there are plenty of people, politicians, religious leaders, unfortunately, talking about queerness, being trans, being gay, being bi, being asexual, being intersex, all of these things as either mental uh signs of mental health difficulties and diagnoses or mental disorders themselves, or just deviant in some way, right? And so the minority stress theory offers good data for saying that is not true. There's plenty of queer people thriving and living beautiful lives, even in the even in the context of experiencing minority stress, but it's the stigma and the discrimination that can build up, particularly when people don't know how to cope with that stress, that then contributes to the mental health difficulties that they might have.

SPEAKER_01 16:22

And really, I guess then, like that's where the DBT side comes in to address those areas. And trying to think, I'm just wondering like how did how through DBT is minority stress conceptualized? Like, what are those ways that DBT comes in and addresses those areas and impacts there?

SPEAKER_00 16:39

Yeah, thank you for asking that because I do think that this can be a useful conceptualization for therapists, even if they're not DBT. So DBT's entire conceptualization model is based around the biosocial theory of emotion dysregulation, which is really short nutshell, is that some people are born biologically predisposed to feeling emotions more intensely, more sensitively, and for longer periods of time. And then when those people grow up in environments that are chronically invalidating to their emotions and their experiences, whether through the form of abuse or neglect or just like a mismatch with their parents, like or their caregivers not really getting it, they won't get the help and support they need for coping with their emotional sensitivity, which then through that ongoing dynamic and interaction can lead to people not knowing how to deal with and understand and cope with their emotions in a way that feels good and in control to them, leading to mental health difficulties, right? Yeah. And so the thing that researchers and clinicians have started to think about more in the past decade in particular is the way that minority stress operates as a form of chronic invalidation. Because what is sexuality and gender and queer desire, broadly speaking, then another internal experience that can be invalidated by the people around you. So even if you grow up in a family that is very emotionally validating and supportive, if you grow up in a culture that consistently is telling you there's something wrong with these parts of your true intrinsic self, you might start to dissociate from those parts, dissociate from other emotions, judge those parts of yourself, have trouble understanding yourself, and then lead to the same type of difficulties that we see in BPD and other mental health difficulties that DBT was created to help with. So there can, I think any therapist can benefit from when working with a clear, a queer client who's struggling with emotions somehow, bringing in this biosocial model of like how did minority stress happen for you in your life? Did it have like staying open to just like did it feel like it had an impact on how you viewed yourself or other people? And bring it into that like biosocial conceptualization of okay, what do we do to help you with it moving forward from here?

SPEAKER_01 19:03

And I I think the book does a great job, but especially with the book really kind of being so heavily influenced by your your experience in providing treatment in this way, like when you're working with clients and working to inform them of that bioso uh biopsychosocial like side, and does that help them reframe that experience as well for them? And so kind of giving an avenue for those thoughts, for that experience, for that perceived wrongness uh you know in their identity and saying, Oh, it doesn't, I don't my internal interpretation might not be as accurate. And it that seems like a really important step. And I think the book highlights that, but in lived experience, what what does that look like? Or what are the what are some of the revelations that come from that awareness there?

SPEAKER_00 19:52

100%. And it's one of the things about DBT that I love, again, of like bringing clients into the therapist conceptualization. Like we make everything super transparent.

SPEAKER_01 20:02

Yes.

SPEAKER_00 20:03

In a way that some people don't like, but I love. And so yeah, actually to do adherent DBT in the initial four sessions, you are supposed to talk explicitly about the biosocial model and talk to clients about their experiences of chronic invalidation. And with a queer client, I would include minority stress as a part of that conversation. And what I would see over and over with my clients, but then what I also experience myself as a highly sensitive person learning about the biosocial theory is the ways in which having this conversation, having more understanding of the ways that you are connected to your environment and your environment influences you can help reduce shame so much and self-judgment and just increase insight of understanding the ways in which, oh my gosh, these significant ways I struggle aren't my fault. Like it can be completely life-changing. And again, it's not in DBT, we're all about dialectics, right? The two seeming opposite things being true at the same time, where we're not saying, okay, it's not your fault, then you don't have to do anything to change it, right? Like actually the opposite, right? Minority stress impacted you. Chronic invalidation impacted you. And now what are you going to do about it? How can you get better at understanding yourself, validating yourself, coping with minority stress? And it just gives a whole new lens of hope and empowerment that I've seen over and over be so helpful for just addressing so explicitly and immediately in therapy. So absolutely, I love that part of DBT.

SPEAKER_01 21:37

And I have to imagine that also just creates such a strong buy-in into like the the interventions and the work itself. And so it's it's almost kind of like that glimpse or like that, you know, you're reading the front cover of uh or the I guess the back cover of a book or the inside leaflet, and it's like just connects and it's like I want more. And so I have to imagine that's just such a such a draw-in to say, okay, I I can understand this, but how do I live it? And it again, I think that's where following through the book, I I see those interventions, those exercises, so those practices and being very crafted very mindfully with that. And over and over again, uh, that the theme of experiencing queer joy is you know, at that central core concept. And would you be open to kind of describing like what is queer joy? I thought you you kind of define it in the book, but here for our audience, like what is queer joy and why is that so important for those that are working with the book or for clinicians or you know, in practitioners in the mental health field if they're working with LGDQ, LGBTQ uh clients, wanting to encourage like that, that's where we want our clients to be is in this experience. And so can you explain that a bit?

SPEAKER_00 22:50

Absolutely. Okay, a lot in that question. So, first, queer joy. I think a lot of times people will view it in like one or two ways, just like, you know, queer people feeling joy and it's queer joy because they're queer. Or queer people doing very stereotypical LGBTQ-coded activities that are fun, like going to drag brunch or camping in your Subaru or going to pride parades, right? And those are absolutely practices of queer joy for some people. But the way that I really try to talk about it is queer joy is the pleasant emotions, whether it's joy or confidence or pride or pleasure, contentment. Relief sometimes, it can be softer, that comes from connecting to your queerness, affirming your queerness, or celebrating queerness of yourself or other queer people. And I make it broader because I think it's really important to absolutely focus on joy and positive wanted emotions, but leaving room for like the full authentic self, which includes all emotional experiences. Like you're not going to have joy if you're not letting yourself also feel the grief. And so, again, dialectical tensions, like, yeah, feeling grief isn't joyful, but it's a necessary part of building a true queer, joyful life worth living. And I think queer joy is so foundational for bringing into therapy with queer folks for a number of reasons. First of all, there's such usually an emphasis in a lot of different therapies, but certainly the psychology field in general on pain and pathology and like getting rid of the hard stuff. Like we already spent most of our time talking about minority stress, right? Yes. And that that makes sense. We want to help reduce those things for our clients, but it can often be at the detriment of forgetting that getting rid of that isn't like the end goal. The end goal is in DBT at least, building that life worth living, like finding the joy, finding the fulfillment, finding the peace. And so when you as a queer person live in a world full of queer minority stress, it can also be transformative to not focus just on that. How do I survive? How do I tread water in this world that's trying to discriminate against me? Um, which is how some of our queer clients will feel. And instead, how can I turn towards, oh, actually, I can feel deeply connected and joyful because I'm queer, not in spite of being queer in a queer phobic world, but because I am LGBTQ. And so it's a really, again, empowering thing to bring that into therapy explicitly and early to help folks who might struggle with that reconnect with joy related to being queer, which can protect against minority stress, but also just help them live more joyful lives, right?

SPEAKER_01 25:43

So and you you I think already answered a few different gave a few different examples of this, but I I want to maybe ask a bit more directly. When you were sharing the reception to creating such an affirming space in practice, a part of that was prior mental health or try uh prior experiences with clinicians. And, you know, even if those clinicians had the best of intentions, they might be missing the mark in terms of creating that that experience and space where queer joy can really be pursued and experienced. And so how do you think therapists most often miss the mark when it comes to supporting their queer clients?

SPEAKER_00 26:22

Yeah, so I think most often it's going to come. Obviously, it depends where you live and like what the culture is around queer people in general. Because obviously, if you have therapists explicitly biased against queerness, you're going to have problems. But I think most of the time it's not that. Most of the time, it usually looks like making assumptions that are really based in a cishet cis heteronormative worldview. And that's kind of a broad feedback. But where I often encourage therapists to improve this part of practice for themselves is beyond, you know, doing the work that you got to do of learning what is every letter in the acronym and like what are different identities that I might face, et cetera, like the stuff you can Google. The thing I recommend even cishet, cisgender and heterosexual therapists do is to actually do their own work into understanding gender and sexuality and not just sexual identity or sexual orientation, but what is my experience of sexuality generally? Because the more that you recognize oh, everyone, or at least most people, have a gender and have an experience of sexuality, the more that you're less likely to kind of stigmatize the client in front of you and not make assumptions about them, recognizing that like everyone's experience of this is different. So, how can I approach this in a informed, culturally competent of LGBTQ people are, but dialectically held with non-judgmentalness and curiosity, cultural humility of what is this person's experience in front of me? So just because they tell me that they are trans, not assuming what that means about what they want to do about pronouns or medical transition or how they feel about trans community, just because someone in front of you tells you that they're married to someone of the opposite gender from them or a different gender than them, that you don't assume that they are straight or that they're allosexual, which is the opposite of asexual, that you really check in with people of like, tell me about your experience. What is your identity? What does that mean to you? Why is this important? And usually, like with all cultural humility and competence for any kind of marginalized group, it's useful to say, hey, I'm cishet. I have worked with queer people before, I've done my due diligence the best that I can. And I want to know what this means to you, right? So missing the mark is making assumptions based on cis heteronormativity, but also making assumptions based on what you know about queer people, right? Because queer people are all different. So just I think cultural humility is the best uh advice that's I encourage folks to try to practice themselves.

SPEAKER_01 29:12

And thank you. Um I'm thinking of what that application looks like, you know, in in my own experience. Uh but I I I want to come into the the term like microaggressions and especially are there any common microaggressions that you think clinicians might display? And I well, let me also ask, would a would a potential microexpression be that assumption? Or be like those assumptions uh made? And are there other common micro or microaggressions that clinicians commonly kind of uh uh let's say unintentionally express or can share that can really sever some of that that that genuineness and that openness that it sounds like can really be cultivated in this empowering environment that we're looking to create.

SPEAKER_00 30:03

Yeah, 100%. So thank you for making it more explicit. Um so the ones that I would hear most frequently from my clients, and then the ones that research is super limited, but from my understanding of some of the research that's like on queer clients, their experiences of therapy with straight clinicians, like what is that like for them? Common microaggressions for sure are making assumptions. So making assumptions based on cis heteronormativity, but also stigmas. So, for example, like assuming the gender of someone's partner, a romantic partner, right? Assuming that someone only has one romantic partner, assuming that someone uh has sexual desires, kind of those things that we were talking about, assuming what someone's pronouns or gender are based on how they look, uh, assuming that, oh, I had another one in my head, but I it is assuming that because someone tells you they're bisexual or tells you the gender of their partner, like either way, like assuming you know something about the other side of it. So if they tell you the gender of their partner, assuming you know their sexual orientation, or if you hear that they are bisexual, assuming something about them that fits into like biphobia or monosexism type of stigma, which is prejudices against like fluid sexualities rather than homosexual or heterosexual, like monosexual types of identities. And I think microaggressions show up on paperwork a lot, like asking for like depending on where you live, like spouse's name or the way you phrase gender identity, or like how you might have someone circle gender identity and theirs isn't there, like you have to be careful about that. Those are really the most straightforward ones that I have heard most often from clients of just immediately, pretty early in the relationship, the therapeutic alliance feeling not safe because that therapist has made an assumption about them that is related to gender or sexuality.

SPEAKER_01 32:01

And if any clinicians are listening and they're recognizing, oh no, I've done that, or I've experienced that with, you know, with their queer clients, like, what do you think that repair can look like? Or is there any kind of general direction you would give to those those clinicians to try to work to acknowledge, reflect, and understand, but then also working to to repair that with the client and or maybe not just assuming, but being able to explore if there had if there's repair needed, I should maybe say.

SPEAKER_00 32:34

Totally. So I think you nailed like there's two sides to it, doing your own work of that research, that reading to understand whether it's bisexuality or biphobia. Like those are different things that might be useful for a therapist to educate themselves on. But then with the client, if you're reflecting, if you immediately notice in the more in the moment that you made an assumption, it's a similar type of recommendation I've heard people make about misgendering a client or misgendering a trans person in general. Just immediately flag it, like maybe say sorry, just use the correct pronoun and then move on. But if you reflect on it later, more later, and you're feeling um like it might be useful to check in with the client, or you notice after the fact, oh my gosh, I totally misgendered them and didn't notice or did the assumption, made the stigmatizing statement. Absolutely. I think like any kind of potential rupture, it's worth bringing up in a way that fits within your theoretical orientation of whether it's between sessions or waiting to the next session, of saying, like, hey, like phrase it in a light way, usually, so that the person knows they don't have to talk about it if they don't want to. But hey, you know, I noticed that the other week I said that, and I was thinking that was pretty biphobic, or I noticed I misgendered you and I'm really sorry about that. Did you notice that? How did that go for you? Do you want to talk about it? If not, that's fine. You know, just kind of again put it into their court. But as the therapist and as potentially this the privileged person, bringing it up so the client knows that is a safe space to address that. And I think that's where even syshet therapists can provide incredibly safe, affirming spaces for queer and trans clients rather than needing a queer therapist to be there.

SPEAKER_01 34:19

And well, I as I kind of called out earlier, you know, it identifies syshet. And so I really try to be mindful of just, well, the variety of other privilege that I carry, not, you know, not only in that, but uh in other ways as well. And are there any other recommendations you would give to, and I would say specifically cishet clinicians or clinicians that maybe feel that they don't have that strongest background in terms of providing that that support that they are looking to, or maybe they're feeling disconnected? How to cultivate that treatment that is really focused on like how do they pushing their clients towards experiencing queer joy? I I love that that term and I want to use that as often as possible here. Like, but are there other ways? Uh and I guess maybe one thought that comes to mind is what are your thoughts on not only doing research, but I think also going into the spaces of the community where allies or where individuals are welcomed and invited and certainly not wanting to impose, but do you find is that an can that be a valuable direction for especially cishet clinicians to kind of go and get their own experience and I guess their own experience of being the minority in specific spaces in a way?

SPEAKER_00 35:37

Mm-hmm. Oh, that last point is interesting. I would say yes. I don't think that it's well, I was about to say I don't think it's necessary. And I think that's the the DVT like pragmatist in me of like, I know everyone's time is super limited. And there are a lot of stigmas that like I would very much recommend white therapists, for example, to get into appropriate, like you're saying, BIPOC spaces and do that anti-racist work specifically, not to like prioritize stigma, but there's like a lot of work that folks often need to do when they hold privilege. So recognizing that there's limits to people's time and absolutely for folks who want to, there are absolutely places, LGBTQ nonprofits, support groups, community centers, that often fairly explicitly delineate this space is for queer people, this space is for queer people and allies. And so going to that allied space and learning more, being involved in nonprofits, mutual aid, support groups, drag brunches, like drag shows, like it can be fun stuff too, right? Like rather than just taking CEs or webinars or reading books about LGBTQ mental health, like it could be watching queer media or listening to queer podcasts. Like all of these are great options for just getting more information about like what is life like for other people, right? Reading memoirs of trans people, of asexual people, of lesbians who are raising kids in like a queer family structure. I think it's all of these things are options. And I encourage therapists to do whatever kind of exploration they want to do for the types of identities that they're finding their clients have that they don't know as much about as they want to, and then going with the things that fit into their lives and their interests. Like some people will love reading books and some people will love going to the community centers, and then they like doing what works for your life.

SPEAKER_01 37:34

Absolutely. Thank you for that. And to to maybe pull back and focusing it on a core element that I hear with DBT of that building a life worth living and pairing that with that experience of queer joy. But why is that especially meaningful for our queer clients of like that focus of DBT of building a life worth living here?

SPEAKER_00 37:59

I'm really glad you asked that question because it's reminding me of when we talked about this earlier. I wanted to say in those first four sessions of DBT, we talk about the biosocial model really explicitly, minority stress with queer clients, but we also very intentionally talk about the life worth living and define that for people. And so again, with queer clients, that's going to involve queer joy and then, or trans joy, bi joy, specific joy to that person's queer identities. And that we do that because it's so important, the way that you're asking about here, of from the beginning orienting to what is the end goal here? Like the end goal of therapy is to help people, at least for most therapists, I think, helping them to build meaningful lives. And I think that's a powerful reframe consistently, but it can be so helpful clinically when things get hard, as they often do, being able to come back to what is the point of this. It is this image of what you want from your life, or it is this queer joy that is accessible to you. We just got to figure out how to get you to it if we can. So I think that it's no matter your theoretical orientation, it can be a brilliantly powerful reframe as a therapist to just have that in the back of your mind and bring your client into it, not only as a where are we going treatment goal type of thing, but to better understand your client. Talking about your their life worth living is great assessment, right? Like, and talking about it over and over is fun. Like it's it's fun to think about the positive things too, which therapy doesn't always do. So lots of benefits.

SPEAKER_01 39:36

And I am wondering, especially if there's individuals that have grown up and with their ex their their experience of being in the LGBTQ plus community is more about surviving than it has ever been about finding that life worth living. Is that a difficult shift do you find for those individuals that have really, I guess, experienced I would say it's significant discrimination in that way? And uh I guess how does that then play in, especially when we're talking about how important it is to create a concept of what that life looks like in comparison with that survival experience that they've had and that rupture or that I guess the disorientation that can come along with trying to conceptualize that. What is that like?

SPEAKER_00 40:24

I thank you for this question. I think it's really important. Absolutely. And I I bet therapists, even if you don't work with queer clients, you can think about if you've worked with depressed clients or suicidal clients. There can absolutely be an intense difficulty to connect to the life worth living. And so for queer folks who have experienced intense amounts of queer minority stress and trauma, there can be an intense difficulty connecting with the idea of queer joy. That is one of the reasons why I've made my definition broader to make it more accessible to folks who are living incredibly difficult lives. Of it doesn't have to be like when you're depressed, you're probably not gonna want to go to the Pride Parade for various reasons, right? And maybe you will, but some people won't. And then if you're not out, or if you hate your body, you might say, like, how the heck can I connect with queer joy when I am surrounded by danger if I were to actually do the things that I want to do as a queer person? So it's really important to meet the person where they're out, of helping them define for themselves what queer joy is. And then as the therapist, helping them end their life worth living generally. And then as a therapist, help them figure out okay, maybe you can't get that exact thing right now. And still, how can you get more pleasure, connection, validation, affirmation, whatever the thing is that can get them towards that? It's really important to helping people just take steps towards this queer joy, towards this life worth living. Did I answer the question there?

SPEAKER_01 42:11

You did, and now I have another question.

SPEAKER_00 42:13

Love it. Okay.

SPEAKER_01 42:14

And I guess it it doesn't only apply to our queer clients, but if there's just the term life worth living. Um I'm reminded, and this was uh if anyone's been a listener for a while, uh, we previously have had David Jobs on, um, and he has a specific model of uh the CAMS model for assessing suicidality. And one of the it's I think it's one of the last two questions on like one of his assessment forms is what are the uh the reasons for living and what are the reasons for dying? And I I just remember him specifically saying that if we're looking at decreasing suicidality, we can increase as many of the reasons for living as we want, but it's really about decreasing the reasons for dying, is what decreases the suicidality. And I almost hear it's the blend of both that creates the life worth living. It does that I don't know if you're familiar with the Cam's model, but like does that concept feel like that resonates here of like it's both decreasing suffering and increasing joy? And it's about leaning into both of that. And so I hear that as even one of those avenues of just the decreased stigmatization could be a part of that queer joy and like that feeling of like I don't maybe feel as much or I'm not lingering in that space as long. Am I hearing that correctly there?

SPEAKER_00 43:26

Yeah, I think you are. So again, like zooming out in a DBT sense, not even queer client specific. Marsha Linahan, the creator of the therapy and DBT in general, really emphasizes the importance of a life worth living. So DBT is not a suicide prevention therapy, it is a life worth living program. Yes. And so I do think as a DBT person, I'm biased towards really wanting to focus on the life worth, what makes life worth living reasons. And totally like top of the hierarchy in DBT treatment is reducing suicidal behaviors and reducing problem behaviors. So there is also the focus on okay, how can we decrease the things that are causing you stress, decrease the things that are causing you problems? So it's always a dialectical balance between those two things where they are both important. And when it comes to queer joy, so often in the community, in the queer community, we talk about queer joy as being protest, as being resilience building. And it is more than that, it exists and is important by itself, but it is hugely important for reducing minority stress, for protecting against minority stress, for preventing future minority stress. Because the more that we connect with celebration and affirmation and connection to queer community, the less minority stress we're going to feel. But also the more empowered we'll feel to cope against it. Like because we know in the research, for example, that so queer kids growing up in states with anti-LGBTQ laws are more likely to struggle with various mental health difficulties just because they live in that state. But there's another mediating factor of the more connection they have to queer affirming caregivers or queer community, the less that impact is. So again, we have both. Like getting connected to queer joy helps protect against minority stress. So they are one and the same in a dialectical way. Yeah.

SPEAKER_01 45:26

And I still feel like quite the newbie when it comes to the dialectic concept here. But but when we're talking about the dialectics, one, I guess, why is that so important here, especially when we're working with our queer clients? And also, is there a specific dialectic focus that you find that you bring into that treatment focus more so with the LGBTQ uh client or individuals that you've worked with, or what is that like?

SPEAKER_00 45:51

That's a great question, too. I don't know if there's so first of all, there are dialectical tensions all over queer mental health, whether it's just being a non-binary person who lives literally in the middle of a binary of gender. And so, how can we help them integrate that identity for themselves? And how can they help we help them navigate living as a non-binary person in this world? That applies to bisexual people too, who live in between the like polar, polarized ends of sexual orientation, people using multiple pronouns, like how can that be true at the same time? So there are very specific queer experiences where having dialectics is so important. But as a clinician, I think that I often come back with queer clients to the primary dialectical tension in DBT, which is the tension between acceptance and change. So, for example, so in DBT in general, that tension is about how can I accept and acknowledge myself and my life exactly how they truly are, while also still working to change that life and myself, the things that I don't like about it. So that applies in general to queer clients, but that applies to minority stress as well. How can we accept, as an acknowledge, radically accept, that we live in a world full of minority stress? And realistically, we're not going to be able to help you prevent all minority stress in your life. Just very unrealistic goal. And how can we still work towards helping you change that world, both on an individual level, communicating your needs to people in your life, getting connected to queer community, learning DBT skills to cope better with minority stress, et cetera? And then also work towards changing the world through activism, mutual aid, et cetera. Like how can we help you reduce minority stress directly, recognizing that we might not be able to? So that constant back and forth is going to be a big part for folks, for queer folks for whom minority stress is a big part of their emotional experience.

SPEAKER_01 47:57

And would you mind I the book I knew does a phenomenal job, but maybe sharing a few of I guess the specific DBT skills that you find kind of work to apply those dialectic or work to reduce reducing the experience of discrimination or the impact that that carries, or if it's challenging some of the stigma and shame, like what are the dbt skills that maybe not all of them, I'm sure we'd be here for quite a while, but maybe highlighting a few of like what are those skills and how does that then work specifically with you know supporting our LGBTQ clients here?

SPEAKER_00 48:35

Yeah, totally. Um yes, 100%. Literally all of them. So there is there is that. And just because I already mentioned radical acceptance of one's life, of one's body, of one's the world one lives in, the experiences they've had, all of that is going to be super relevant for queer folks around minority stress, the way we just described, but then also problem solving on a big scale and a small scale, the way we just described. I think that the really big ones for queer folks specifically, one of them is going to be well, we've already been talking about this, but accumulating positives specifically related to queer joy. So, how can we very directly and purposefully go into planning and appreciating and savoring queer valued activities or queer pleasurable activities? So viewing it as a direct skill intervention in that way, practicing queer joy. And that one will often be a type of practice, but of opposite action. But that's the other big one that I think is worth mentioning. When we, as queer people, live in queer phobic culture, as we've said multiple times, we're much more likely to struggle with anxiety and shame, both generally, because that's how that works, but to gender and sexuality in queer ways of being specifically. And opposite action is in a DBT sense like the name of the game when it comes to decreasing chronic anxiety and shame. So, how can we see these emotions, recognize them and validate them and understand them, but then choose to act opposite to them when they are not helping us anymore, the way they're often not helping us when it comes to shame of being queer? And helping our clients find ways to overcome that shame, whether by practicing self-compassion in various ways, practicing self-eludation and affirmation of queerness and queer identities, practicing queer joy as opposite action to shame and anxiety, right? So so many DBT skills are going to be captured under this opposite action framework. And that's why I think it's such an important one to point out.

SPEAKER_01 50:45

And uh again, uh just truly numerous resources and examples in the in the book. Um, and you know, I find myself going through, and I was marking down specific ones that I was hoping to kind of bring into the session for myself when kind of uh working with certain individuals and finding ways of taking that. So certainly it is not, I don't I think there's the target audience and then the secondary audience of you know, you you at home listening, just a wealth of resources here. And I know we're soon coming to our time, so we should probably start pulling back. But um, you know, Kiki, I appreciate kind of hearing all of these uh this the skills, the focus on dbt. And maybe as we're starting to pull back, one well, one question that we like to ask is um do you have any content or a what a piece of content that you would recommend? So if that's a book, movie, TV show, podcast, etc., um, for those in the profession, what what would that be?

SPEAKER_00 51:41

Yeah, so besides my book, the the book that I would recommend um is one written by John Pachenkis. It's called Transdiagnostic LGBTQ plus affirmative cognitive behavioral therapy. So if you're interested in CBT, DBT, John Pachenkis and his fellow authors have written a fabulous therapist guide that deeply influences my work as a DBT clinician, working with queer clients too. So I do recommend that book.

SPEAKER_01 52:09

And if you could, I guess, kind of distill down like three different like gems or takeaways for clinicians surrounding the topics we talked about in this episode, like what would they be?

SPEAKER_00 52:21

Yeah. Some will repeat myself, some I won't. The first is include queer joy, right? Like, really at the end of the day, I think that's the main takeaway I want folks to have of queerness can be a place of pleasure, pride, positivity. And so helping clients find that is so important. Two is to know the LGBTQ acronym, the umbrella, the identities, but not make assumptions, right? So that cultural humility piece. And then three related is to do your own work around gender and sexuality of understanding what is my gender? How do I know that? What is my sexuality? How do I know that? And not viewing it as the work that only sexual and gender minority marginalized people have to do. Like it's something that can greatly inform our own self-understanding and compassion for ourselves and others, no matter who we are. So those are the three I'd say.

SPEAKER_01 53:16

The phenomenal three, and you know, ones I know I'll be taken to heart, and I hope you know you at home listening do as well. And you know, that this has been wonderful, Kiki. Thank you so, so much for you know, taking an hour to sit down and really kind of going over your new book, but also being able to take it and really expand beyond the book and do, you know, for clinicians and being able to give a just some some concepts or a framework that they can start and you know, kind of their pathway of helping others experience queer joy or you know, for themselves being able to better understand what queer joy is and yeah, but some self-reflection along the way. And so uh thank you for joining us. And you know, if our listeners are interested in following you or hearing more, where can they go to hear what's going on for you?

SPEAKER_00 54:02

Yeah, so the best place where you can find everything is my website, which is my name, so kikifailing.com. But I am also on most social media at dbtkiki. And the two resources I want to point out based on our conversation today is I do write a substack all about queer joy. And so it can offer even uh non-queer therapists a way to understand maybe what queer joy practices could look like. And then because we didn't get to talk about opposite action to shame, there is uh new Harbinger, my publisher, and I have this link to on my website too, offers worksheets from the book that walk through how I can help a queer client differentiate and understand when to act opposite to shame and when is it not safe to, because we do live in a queer phobic world. And so that balance that's available for free for folks if they want to learn more about that topic.

SPEAKER_01 54:52

And if you are interested, uh we will have that in the show notes and uh you know, certainly hoping you check that out. And if you're a licensed clinician who would like to use this information, please head over to www.sychtopractice.com or check the show notes for a link to purchase an accompanying exam for continuing education for this episode. If you're interested in hearing more and staying up to date with what's going on for Psych2 Practice, you can visit our website or follow us on all major social media by searching Psych to Practice. We'll be back in two weeks, but until then, be well. Stay psyched.