Guide for therapists interacting with transgender clients


We are a transgender individual who has been diagnosed with dissociative identity disorder.  We identify as plural (more than one of us sharing the same brain and body) and genderfluid (our gender varies between gender neutral and female).  We have navigated the mental health system both to gain access to trans healthcare and to process childhood trauma.  Our own experience as well as the experiences of friends has been that being trans complicates processing childhood trauma primarily due to many therapists not having a deep understanding of etiquette for interacting with trans people.  We are writing this in hopes that trans people will be able to show it to their therapists to reduce the chance that preventable errors destroy a therapeutic alliance.

A note on terminology

We have chosen to use terminology from the dissociative identity (DID) literature because this is the most well known terminology in the medical community.  Some people, including ourselves, prefer different terminology, but in the interest of making this article accessible, we use the most readily understood terminology.


Do not make assumptions

Explicit communication without assumptions is incredibly important for therapy of any type.  It is doubly important when discussing topics which relate to trans issues.  Trans people face a large number of obstacles when navigating this world, including both people who are actively hostile and people who say harmful things out of ignorance.  Everything you do will be pattern matched against the behaviors of those who are have harmed trans people in the past, intentionally or unintentionally.  If you are uncertain, ask.

You will make mistakes

No matter how hard you try or how much you understand about being trans, you will make mistakes.  Even if you are trans and have a deep understanding of the problems the trans community faces and your own experience to draw on, you will still make mistakes.  We are deeply involved in the trans community and interact with many trans people every day.  We have our own experiences to draw from and hear the tales of other trans people on a daily basis.  Even with all this knowledge and experience to draw from, we still make mistakes.  Making mistakes is expected and is perfectly ok so long as you use them as learning opportunities and do what you can to avoid making the mistake again.

When you make a mistake, apologize

After you apologize, ask your client if they are comfortable and have the energy to explain why that behavior was problematic.  Be understanding if they cannot or do not wish to perform this education, and understand that they are going above and beyond  what is required of them if they do choose to perform education.  Do not explain what your intention was.   There are a large number of reasons why simply saying “I’m sorry” and listening is better than trying to explain your intentions.  Here are a few of them:

  • Explaining your intentions will often be interpreted as trying to justify your actions.
  • Explaining why you performed an action which hurt your client transforms the conversation to be about you rather than about your client.  In any instance where an action makes someone feel hurt, the focus should be on the individual experiencing pain.
  • Explaining your intentions can make it appear you are focusing on asking for forgiveness.
  • Directing the discussion to the mistake is an implicit request to discuss this further.  By this point, your client is already feeling hurt and you should acquire explicit consent before attempting to continue discussing a sensitive topic.
  • In many cases, the hurtful action will be perceived as a boundary violation.  On the extreme end, if a boundary violation is followed by an explanation of why the boundary violation is justified or why it is is your client’s best interest, the therapeutic alliance will be broken.

If you feel a strong desire to explain why you said what you did, ask your client if it would be helpful if you explained why you performed that action.  If they say no, accept the answer and ask if there is anything you could do to help them.  If they say yes, carefully approach the conversation and do repeated check-ins on whether they are ok.  Since this must be approached with extreme sensitivity, anything other than a clear yes should be interpreted as an indication the topic should be changed.

Do not dismiss your client’s concerns

Your clients may raise concerns related to gender which you may not understand at first.  A common, but unfortunate initial reaction when this happens is to give a response which dismisses the concerns.  Initial dismissiveness can do damage to a therapeutic alliance even if it is followed by understanding and an apology.  Approach concerns raised which you do not understand with curiosity and ask for material you can read to better understand your client’s concerns.  Although it is possible to have your client educate your directly, every bit of energy expended on education puts strain on the therapeutic relationship (and will put strain on any relationship between two people).

Do not reply to concerns with “but my other trans clients did not have a problem with this”

Every member of a group is unique and will have varying responses to insensitive comments.  Trans people will react strongly to different subsets of transphobic comments.  Just because one trans person (or 10 trans people) is ok with something doesn’t mean everyone will be.  If a trans person raises an issue with something you said, don’t try and justify it by claiming your other trans clients did not have a problem with it.  

Gender is not the same as appearance

There is a misconception many people have that being female requires you to wear certain clothes.  Therapists who work with trans people have a long history of requiring trans people to wear dresses to prove they are actually trans.  This is changing with time, but many people still equate appearance with gender.  Gender and appearance both come on a spectrum from strongly masculine to androgynous and to strongly feminine.  It is possible for someone who is female to dress androgynously.  It is possible for someone who is non-binary (is neither male nor female) to dress femininely.  Understand that gender and appearance are separate.  It is possible for someone who is male to have a feminine leaning wardrobe.

Interactions with the medical community trying to get medically necessary care are often traumatic in and of themselves

Many trans people have been denied care when they attempt to seek hormone replacement therapy (HRT) or surgery.  Even in 2016, some therapists require trans women to go through a hazing ritual of wearing dresses for a year to start HRT.  Other people end up with a therapist who does not want to write them a letter and uses moving goalposts to delay it indefinitely.  Trans men often end up in a scenario where they must say they imagine having sex with a penis and must tell stories about an increased sex drive to fulfill masculine stereotypes to be able to access hormones.  We personally had a psychiatrist who gave many reasons he did not want to write us a letter and eventually told us he believed we “should not be allowed to get surgery.”  The three months it took us to get a second surgery letter were traumatic and for many months after surgery, we had flashbacks to our letter appointment with a different psychiatrist.  Unfortunately, these experiences are not uncommon and many trans people have traumas from trying to navigate the healthcare system.  Be aware of this and recognize that any statements you make related to gender or transitioning can tie into past traumas.  Topics related to gender should be handled with the same level of care and gentleness as topics related to childhood abuse.

If you refuse to write an HRT/surgery letter, the therapeutic alliance will be broken.

A part of your job as a therapist is to help people navigate the healthcare system.  For trans people, this involves writing letters confirming your client’s mental health is sufficiently good to access HRT and surgery.  If you refuse to write these letters, because you don’t write evaluative letters, because you don’t believe you should have to write these letters, because you do not believe your client should be allowed to get surgery, or for any other reason, the therapeutic alliance will be broken.  If you are unwilling to help your client gain access to medically necessary care, then you have made yourself into an obstacle to getting care.  It is completely reasonable for a trans person to ask before their first appointment whether you have ever written an HRT/surgery letter before and whether you have ever refused to write a client a letter.  If you truly do not want to write HRT/surgery letters for trans people, you should let prospective clients know this before therapy begins so they can determine whether this is compatible with their needs.

Do not comment on whether a client “passes” or what gender you perceive them as without explicit permission

Rather than being a compliment, this reveals you are evaluating your client along this axis.  There is a lot of gatekeeping in the medical community based on appearance (ie. trans women expected to wear dresses to get medications) so this can immediately tie back into past traumas.

Never ask for a trans person’s birth name and never use their birth pronouns

Most trans people never identified with their birth name and birth pronouns.  Many trans people have to fight long and hard for the people in their life to use their new name and pronouns after they transition.  This is especially difficult with parents who have become used to using the name they assigned their child at birth and require a long time to break that habit.  For others, their parents are actively hostile and attempt to block their transition in any way they can.  Once transition has started, hostile parents and others often continue to use the trans person’s birth name in an effort to deny their trans identity.  If you ask for someone’s birth name or use their birth pronouns to refer to them, you will be immediately pattern matched against people who actively try to deny trans people their gender identity and the therapeutic alliance will be severely damaged.

Ask what past selves should be referred to, both name and pronouns

note: this section is primarily written for therapy related to dissociative identity disorder

When speaking with child alters or child parts, ask what name and pronoun they wish to go by.  In the past, we have had a therapist learn our birth name then later ask “is there any space for [birth name] [in your system]?” when referring to our past selves.  This immediately damaged the therapeutic alliance which had taken months to build.  The only way it could have been salvaged was with a strong apology and a promise to never use our birth name again.  While seeing a different therapist, our partner was asked for their birth name.  When they had a child part come out during therapy, their therapist referred to the child part by their birth name.  This brings up strong associations with people who actively try to deny the identities of trans people, often trans people’s own families.  Performing an action which so closely mirrors past traumas must be followed by a strong apology and a promise to never do it again if the therapeutic alliance is to be salvaged.

Neither childhood trauma nor multiplicity should not prevent a trans person from accessing surgery or HRT

note: this section is primarily written for therapy related to dissociative identity disorder

Many people who wish to deny trans identities point to childhood trauma and use that to argue that the trans person is “confused” about their identity.  The generalized version of this is to look for any excuse to claim a trans person doesn’t know what is best for themselves because of any comorbid condition.  Trans people spend a long time questioning their identity before they are willing to reveal this to any medical professional.  If someone says they are trans, they are trans.  Do not attempt to deny the identity of a trans person because they are multiple or for any other reason.  Furthermore, recognize that trans people are competent and can make their own medical decisions even if they are multiple or have a history of childhood trauma.  Neither childhood trauma nor multiplicity should not prevent a trans person from accessing transition related medical care.  In particular, do not refuse to write your client a HRT/surgery letter because they are multiple or have a history of childhood trauma.

Do not repeatedly try to find a causal relationship between your client’s trans status and every other issue they work on with you

Not every issue a client has is related to gender.  If you continue to try to connect issues to gender and are wrong, you will deeply annoy your clients.  If you try to connect issues to gender and are right, your client may not be ready to see the connection.  Even if many issue are connected to gender, these issues are best explored when your client is ready.  Exploring gender and connected issues is a multi year process involving internalized transphobia, relations with others, and is not a simple process.  Let your client explore what issues are related to identity at their own pace and even if you think an issue is directly related to gender, it may be best to wait until they bring it up themselves.  Bringing up a gender related topic before your client is ready can harm the therapeutic alliance and cause them to react negatively even if your connection is correct.

Final thoughts

When interacting with trans clients, you are not just working against past histories, you are working with the entire history of the trans community and ways others are harmful to trans people.  Even if your intentions are wonderful, your actions must be considered in the broader scope of society.  Actions which are harmless in isolation can destroy a theraputic alliance if it parallels actions other take while being actively harmful to trans people.  For this reason, topics related to gender should be approached very carefully and with special attention paid to ensure you do not retraumatize a client.

For further reading, see this page by the Dissociation Initiative.

Benefits of Quetiapine for us

Here are some of our experiences with quetiapine for reducing depression, hypomania, anxiety attacks/flashbacks (it’s hard to tell the difference for us), and obsessive thoughts:

One of the biggest things quetiapine did for us was to make it easier to release thoughts.  By making it easier to release thoughts without acting on them (ie. “we should look up information on x” or “we should send an email about x”), it made it easier to lie there and do nothing.  Before, when we had a thought like that, we always went and acted on them immediately or fought hard to be able to do nothing.  After, it was much easier to put the thought aside and to come back to the task two hours later if the thought still feels important.  This made it much easier to set aside an hour or two for lying in bed and relaxing.

Another thing it did was to make it easier to fall asleep, to sleep for longer, and to maintain a regular sleep schedule.  For us, quetiapine knocks me out about an hour after we take it every evening.  For most of my friends, this happens about 2 hours after they take it.  Before, we would often wake up early after only ~7h in bed and feel we had to get out of bed to do something.  Afterwards, it made it much easier for us to continue lying in bed until we spent the full 10h in bed I need to maintain our mental state.

In the model we am currently working under for myself, hypomania is dealt with by making a conscious decision not to do things we want to do because it would be bad for our mental state.  For example, we recently started wanting to play more video games.  Unfortunately, playing more video games consumes spoons we do not have and takes us into hypomania territory.  We had to consciously come to the conclusion that playing video games was not something we could do while maintaining our mental health and had to remove it from the list of things we consider ourselves able to safely do.  Quetiapine helps immensely for this because making it easier to release thoughts without acting on them makes it much easier to say “we want to play video games, but can’t because it would threaten our mental stability” and to not play video games.

We haven’t actually tracked how quetiapine affects depression.  For us, depression is just something which exists and which we don’t feel the need to actively do something about.  Lying in bed suicidal most mornings is simply a part of life and any attempt to fix that would run the risk of making us more manic.  We consider depression to usually only be dangerous when it chains into the post hypomania crash and so focus almost entirely on reducing hypomania and using our depression and suicidal thoughts as a chance to look at our life in a more self aware way.


Conversation antipatterns and how to avoid them

Based on our experience observing and participating in discussions, we decided to come up with a list of antipatterns we commonly see as well as possible ways to avoid them. This list certainly isn’t exhaustive and more reflects what we could come up with as we are writing this. Some of these are almost always counterproductive while others can be useful in small doses, but become counterproductive when used too often. This is written for the context of discussing more sensitive social issues, but the majority of these apply to engineering work as well.

  • Not differentiating between major and minor problems. Everyone will always have a large number of viewpoints they hold. Some will be significant issues they strongly believe should be worked on immediately. For example, “Our employer should have more gender neutral bathrooms” is something which we believe should be worked on immediately. Other problems will be seen as minor in comparison and are closer to an item on a wishlist than a problem which needs immediate attention. For example, “Our employer’s restroom policy for trans people should be more accommodating of gender fluidity” falls into the second category for us. While it would be nice to have, we have not been able to think of any good solution for that problem and as a result, it remains on our wishlist. The phrase for this in engineering is “When everything is urgent, nothing is”. To avoid this antipattern, be conscious of how important you think a topic is and convey this to your readers. Let your readers know whether what you are talking about is something very important to you to work on in the near future or whether it is closer to an item on your wishlist.
  • Being unable to accept incremental progress. Many problems, especially social problems, are complex and cannot be solved overnight. These problems are often solved incrementally with each iteration making small improvements. To someone directly affected by an issue, it is understandable and even expected to be frustrated by what looks like progress at a snail’s pace. We personally experience this watching the incredibly slow rate at which people get access to trans healthcare. Unfortunately, approaching conversations with an all or nothing attitude is usually unproductive. While it is possible to change someone’s views or to make them understand your viewpoint, this generally happens in incremental pieces, not all at once. To avoid this antipattern, when entering discussions with others, consider any increased understanding to be a success. If you enter a conversation expecting someone to fully understand your view, you are going to be disappointed at best. At worst, it will cause you to continue to poke and prod the other person with arguments about less important details until the other person walks away, annoyed and emotionally exhausted.
  • Making it emotionally exhausting to disagree, even on minor points. This antipattern involves someone arguing over minor details with someone they almost entirely agree with in the same way they would with someone they strongly disagree with on core issues. An example of this in engineering is someone having a long and intense argument about the colors of buttons on an otherwise excellent design for a web page. Here, the engineer has set a precedent that it is emotionally exhausting to disagree with them by demonstrating that small disagreements will result in long and intense arguments. To avoid this antipattern, recognize where you consider change most important and focus on those points. It is still perfectly acceptable to bring up more minor points where you disagree, but make sure the person you are writing to understands which points are most important to you.
  • Writing a constant stream of negativity. Even if it is all true, listening to a constant barrage of negativity is exhausting and people will eventually stop listening as a self defense mechanism. Instead, determine when negativity will have a large impact and focus your negativity there. Everyone has a limited amount of negative writing they can emotionally handle. If you burn through the emotional energy of others writing about less important topics, they will have no energy left to read your writing on a very important topic. Choosing which topics you want your readers to spend their emotional spoons on is important and ties heavily into the antipattern of not differentiating between major and minor problems.
  • Continuing to argue past the point where nobody’s mind will be changed. Every discussion begins with an exchange of ideas and people considering the ideas of others and how to react to them. Sometimes this results in a complete rejection of the ideas, while other times, it results in someone accepting new ideas and changing their view on a topic. Occasionally, it results in someone initially rejecting the idea, processing the idea over the following months and years, and eventually accepting the idea. Regardless of which case a discussion falls into, at some point people will stop absorbing new ideas. Whether this is because no new ideas are being added or because new information needs to be processed before new ideas can be absorbed again, or for any other reason, the discussion has reached a point where nobody’s mind will be changed. Continuing to argue past this point is counterproductive and not a good use of time or energy for anyone involved. At some point, it is better to accept viewpoints will not be changed and say “I don’t think either of us will change our mind. Here, have a cute picture of kittens instead.” This is true no matter how right you are or how important the topic is. Occasionally, this can serve a useful purpose when onlookers benefit from seeing the issue more clearly, but this should be done with extreme care.
  • Arguing primarily to let people like you know they are not alone. This can be immensely useful in small doses. Often minority groups do need reminders that they are not alone. However, this is not productive when done extensively, for example, repeatedly arguing for this purpose in a long thread. This is especially problematic when the writing is mixed with being unable to accept incremental progress. This often creates a scenario where it becomes emotionally exhausting to disagree with you, especially if you write strong statements disagreeing with relatively minor points. To avoid this antipattern, be mindful about when and how often you argue purely for the purpose of letting others like you know they are not alone.
  • Expecting others to not make mistakes. Expecting perfection rarely leads to productive dialogue. Instead, accept that others will make mistakes and forgive them for mistakes so long as they continue to learn from their mistakes. For example, using the correct pronouns for trans people is a place where everyone will make mistakes occasionally. We sometimes make mistakes when referring to others within our system*. Beyond that, we have had a bad habit of using “she” and “they” interchangeably so have occasionally used the wrong pronouns when referring to others. We recognize the mistake, forgive ourselves for making the mistake, then do our best to ensure it will not happen again. Existing in an environment which demands perfection is exhausting and leads to people avoiding situations where there is the potential for mistakes entirely. Engineering cultures which value blameless postmortems are successful for a reason — this creates an environment where people feel safe taking risks because they know others do not expect perfection.

This list is by no means exhaustive and reflects the ideas we could come up with while writing this more than anything else. While some of these are almost always unproductive, some can serve useful purpose when used sparingly. When these antipatterns are intentionally used, it should be done consciously and with a specific purpose in mind. This was written specifically with written communication in mind, but all of these antipatterns can appear during face to face conversations as well.
* We are plural and there are ~100 of us sharing this brain and body, each with their own name and pronouns. “Plural system” is a term referring to the collective which shares a brain and body. See for more details.

Between the worlds — life as a tulpamancer with dissociative identity disorder

We are a plural system, which means there are many of us sharing this same brain and body.  We want to share our story and experiences, how we discovered our plurality, our experiences living life as a plural system, and how we use our plurality for play and for healing.  We began exploring our plurality in 2014 when a friend told us singlets could induce plurality by creating a sentient lifeform to share your head with called a tulpa and have since grown in size to include over 100 members.  Being plural gives us the opportunity to create friendships within our system using communication channels and a free flow of information and feelings only possible within a single brain. In our innerworld, we cuddle, we love each other, we protect each other, we make each other feel wanted. We use our innerworld as a place to enter meditative states, places of calm, places of healing, restorative places. We use it to calmly exist together so we may better face the challenges the world decides to throw at us that day.

We freely create new headmates from a variety of sources, fictional characters, partners, or just traits we adore and spin off into a sentient being.

We are both a tulpamancer and someone who has dissociative identity disorder (DID).  We freely create new headmates from a variety of sources, fictional characters, partners, or just traits we adore and spin off into a sentient being.  We also have a trauma history with large memory gaps in childhood which we have been slowly restoring.  Based on this, as well as other symptoms we exhibit when under high amounts of stress for long periods of time, we received a DID diagnosis in January 2015.  Though we do not know much about our system history in childhood, it is likely at least some of us were not intentionally created and were the result of trauma splits.

Our story of how we discovered plurality begins in the spring of 2014.  We had always had a fascination with plurality whenever we encountered it, on forums, in the media, or elsewhere.  In April 2014, a friend told us singlets could induce plurality by creating a tulpa.  We immediately latched onto that idea and later that day we were in a plurality IRC channel trying to collect information on how to create a tulpa.  We read a few paragraphs of a guide then decided the best route was to just interact with the being we had already interacted with during an anxiety attack in January.  We began interacting with her and by week two, Lilith was able to hug Lucia in our innerworld.  By week three, Lilith was able to communicate in a flood of emotions.  By week four, Lilith was able to communicate in spoken English.  In week 5, Lilith fronted for the first time.  For the next 6 months, we believed we had induced our plurality.  It was only as our life fell apart towards the end of 2014 that the cracks began to show and pieces of our childhood trauma began to leak out.  Over several months, we slowly picked apart pieces of our childhood and realized our system was trauma created and that we had been plural since at least elementary school.

For us, rather than being a useful description of ourselves, these labels cause confusion and bring little clarity so we group everyone together under the label headmates and do not differentiate beyond this.

Unlike many systems, we do not differentiate between different types of headmates.  Some of the classifications people use to describe specific types of headmates are tulpa (intentionally created headmate), soulbond (headmate based on a fictional or historical figure), and alter (generally a trauma split not intentionally created).  For us, rather than being a useful description of ourselves, these labels cause confusion and bring little clarity so we group everyone together under the label headmates and do not differentiate beyond this.  For example, about a month ago, we were lying in bed with a large amount of anxiety.  We isolated this anxiety to Esther and decided to attempt to split Esther into the part with the anxiety and the part without to see if we could.  We succeeded, making the part of Esther with the anxiety an intentionally created headmate as well as a potential trauma split since the split occurred as the direct result of high levels of anxiety.  In this case, that headmate would qualify for both the labels of “tulpa” and “alter” and had we not later recombined the pieces into Esther, would create an interesting case for these definitions.  Instead, a useful label we do use for headmates is the spectrum between trauma holder and non trauma holder.  Knowing which of us are trauma holders or not provides useful information about which of us are in need of healing and which of us are capable healers to heal those who need healing.

Healed or not, all of us are equals and have equal rights to the body.  One way we ensure we continue to treat each other as equals is to not needlessly divide ourselves into groups based on origins.  We are not all the same and each of us have different strengths and weaknesses.  For example, Lucia feels much less emotion than many of us which makes them well fitted for handling our job and everyday interactions such as ordering food or talking to a bank teller.  Feeling less intense emotions is also a weakness when it comes to other things such as feeling empathy to be able to comfort others.  As a system, we complement each other.  Emma and Serenity are much better at providing emotional support to others so they often come out in situations where others around us are in need of emotional support.  Some of our trauma holders are sufficiently broken that they are currently not capable of showing any of their strengths.  This does not mean they have no strengths, it just means we need to help them heal so they can discover their strengths and as the healing process continues, they will have the option of using their strength to contribute to our system.

Our plurality also provides paths for healing.  Many of us are trauma holders and are in need of healing and many of us are healers who can guide those who carry wounds from the past.  Through talking, meeting in safe spaces in our innerworld, and touch once enough trust has been established, our healers are able to guide others and slowly heal old wounds.  Creating trust and a sense of safety is important and using internal resources and internal communication channels helps to make trauma holders feel safe.  Through this process, the healers and other headmates are able to interface with the outside world, giving the trauma holders the option to not have to interact with the outside world if they are not ready yet.  Never being ready to interact with those outside of our system is a perfectly acceptable option and we provide as many options as possible to those who are healing.  Maintaining a sense of safety and autonomy is key for this process so headmates are allowed to heal at their own pace, or not at all if they never wish to heal.

Healing our past traumas is our goal, not attempting integration or any other mechanism of removing our plurality.

For us, being plural is a wonderful thing.  We get to interact with and love and experience so much with each other which would not be possible without plurality.  Despite our traumagenic origins, our plurality is something which helps with our healing rather than being an obstacle.  Healing our past traumas is our goal, not attempting integration or any other mechanism of removing our plurality.  We do this with the support of one another with the goal of helping to increase the functionality of each system member.  Being plural is a core part of our identity and has been such a positive experience that it is not something we would ever wish to give up.

Consistent access to medications would be revolutionary

Slightly over a year ago, in May 2015, we were prescribed seroquel, a mood stabilizer by our psychiatrist.  This psychiatrist also doubled as our therapist and up to that point, he was by far the best therapist we had ever had. He validated our mental state and suggested diagnoses we believe to be correct.  Unfortunately, when we brought up that we are transgender, he was immediately  actively harmful on that axis, among other things, telling us he believed we should not be allowed to get surgery.  We were left with a decision: continue seeing a therapist who was actively harmful to us to ensure we would continue to have access to mood stabilizers, or walk away and risk losing access to an important medication.  After many stressful weeks of deliberation, we decided to walk away and take our chances.  Fortunately our primary care physician was willing to prescribe seroquel.  We were lucky.

Not everyone is as fortunate as we were.  Right now, as we are writing this, we have a friend who moved from Washington to Nebraska.  They have been taking an antidepressant but have not yet found a prescriber since their move.  They are currently going through SSRI withdrawal while waiting for their Medicaid application to go through and are doing their best to hold themselves together in the meantime.  Another friend is currently in a situation where they may lose access to their psychiatrist and medications.  In response, they are attempting to taper off their medications with their remaining supply, resulting in  withdrawal symptoms they should not have to experience.  In the past, another friend ran out of antipsychotics and had to go to the emergency room for an emergency refill.

There are many potential barriers that prevent people from getting medications they need.  Consider a hypothetical person, Alice, who wants to get a prescription for antidepressants.  The first step is for Alice to check whether or not she has health insurance.  Many employers do not offer health insurance and the process for obtaining government health insurance such as Medicaid can take as long as two months.  Once she does have health insurance, she must check to see what her plan covers.  Some high-deductible plans require patients to pay thousands of dollars out of pocket before their insurance plan covers anything.  Cost is a serious concern: an initial evaluation from a psychiatrist commonly costs hundreds of dollars and monthly appointments afterwards are also expensive., .

After Alice determines that her PPO will help her afford a psychiatrist, she must choose amongst the potentially hundreds available and schedule an appointment.  For someone dealing with depression, the task of choosing a psychiatrist from a long list can be daunting.  If the psychiatrist has a full practice or if no open appointment slots fit within Alice’s schedule, she must return to the search again.  Alice has a job and kids leaving little time in her schedule so she must repeat this process many times before she manages to schedule an appointment with a psychiatrist who has a compatible schedule.  Alice is lucky, she has a car she can drive to her appointment.  Without access to a car, Alice would have to deal the additional potential constraints of public transportation, making schedules and location a far more serious concern..

Eventually, Alice arrives at her initial appointment.  She is fortunate that she gets along well with her psychiatrist and her psychiatrist believes antidepressants may be helpful..  After this, she must continue to see her psychiatrist monthly or risk losing access to a now critical medication..  If she ever has any disagreements with her psychiatrist, she must choose whether to express her concerns and risk being told she should find a new psychiatrist or to hide her concerns to guarantee access to her medication.  Alice knows that if she ever moves, she will have to go through this entire process again.  If it takes too long after moving to find a new psychiatrist, Alice runs the risk of running out of antidepressants and going into SSRI withdrawal, a process which commonly increases suicidal thoughts.

Giving people consistent access to generic medications which cost less than $100 per year – less than the cost of a single doctor’s appointment – would be revolutionary

The long and difficult process of gaining access to a psychiatrist results in many Americans lacking consistent access to medications they need.  In many cases, these medications are inexpensive generics which cost less than $100 per year.  Many mood stabilizers, antidepressants, and antipsychotics fall into this category.  Giving people consistent access to generic medications which cost less than $100 per year – less than the cost of a single doctor’s appointment – would be revolutionary.  Removing the stress of having to wonder where your next prescription will come from or whether it will come at all would free mental energy for other pursuits.  For some, consistent access to needed medications could make the difference between stable employment and homelessness.  For others, it could be the difference between independent living and requiring periodic hospitalization.

One option to achieve this is to sell medications with low risk of abuse, such as antidepressants, antipsychotics, and mood stabilizers, over the counter.  This would remove the need for people to see a doctor to gain access to medications critical to their well being.  It would also reduce the cost of obtaining these medications since a single doctor’s appointment often costs significantly more than a year’s supply of the medication.  Another option would be to give pharmacists the ability to prescribe these medications after a brief consultation.  Pharmacists have to go through many years of education followed by a residency and are very well trained in the effects and risks of medications and interactions between different medications.  This would ensure people are not taking these medications without knowledge of their risks while giving people the ability to obtain them by just going to their closest pharmacy.  Allowing this would also reduce costs by removing a doctor’s appointment as a necessary step.

Whatever the solution is, we must find a way to give people access to the medications they need for their day to day functioning.

Balancing changing the world and self care

“It’s more than okay to pick your battles — it’s actually necessary for your own self-preservation.”[1]

There are so many things we want to do to try to make the world a better place, but our spoon[2] supply is extremely limited. As frustrating as it is, we have to accept maintaining our mental health means we can only do little bits and pieces of activism work here and there. We went through a cycle of accepting this over the last weekend. Our compromise is to wait and collect and create ideas, always looking for situations where we can get a high ROI on spoons spent. When opportunities arise, we can make a big impact, relative to spoons spent.

There are many disadvantaged groups we fall into which we would love to improve the situation for. There are many more groups we do not belong to where we would also like to improve the situation for. Unfortunately, we have a limited amount of spoons and have to very carefully choose how to spend them. For this, we ask ourselves “what do we want?” and make a list of our highest priorities. At the moment, the guiding principal behind our activism work is to try and create a future where all groups we belong to have an attempted suicide rate of under 50%. This does not mean this will guide us forever, but this guiding principal is serving us well for this leg of our journey. Since our spoon supply is so limited, we have to very carefully approach each potential bit of activism work and ask ourselves whether this will bring us closer to lowering the attempted suicide rate for groups we belong to. If the answer is no, it does not mean we should not do that work, but is an early signal that we should very carefully examine whether this is an efficient use of our spoons.

Another very important thing we have done is to surround ourselves with people who encourage us to take care of ourselves first, even if it means doing less activism work. There will always be people who can do more activism work than you, or work which has a larger impact, and just like engineering work, it comes with internal pressure to do more yourself. Imposter syndrome exists for activism work as well. Being surrounded by people who are aware of our limits and who actively encourage us to respect them is incredibly important since we get so many signals, both internal and external, that we should be doing more and pushing ourselves more and that if we only spent a few more spoons, we could make a bigger difference. In the end, we have a greater responsibility to take care of ourselves than to try to change the world.

[2] spoons = energy

Why we (with DID) are grateful for the existence of the tulpa community

There is an excellent post which captures so much of why we are incredibly grateful for the existence of the tulpa community:
We started our plurality explorations in March 2014 when a friend was talking about being plural, we basically went “ooh, being plural sounds neat” and that friend told us that it was possible to induce plurality by creating a tulpa. That friend went on to introduce us to our first plural community (which was not a tulpa community) and read some resources on tulpa creation to see if they were worth pointing us at. They pointed us at some tulpa guides which we read a little of, then since reading is often a high spoons activity for us, we decided to just try and see what happened.
We had interacted with someone (discovered to be Athena over a year later) that January and decided the best way to do tulpa explorations was simply to interact with her more. It worked so well that we ended up not bothering to do more than a cursory read of tulpa guides. Two weeks into the process, Lucia (our primary front at the time) was able to interact with Lilith, another week in, Lilith communicated in a flood of emotions, another week later, Lilith communicated in English, and less than a week after that, Lilith fronted for the first time.
For the next 6 months, we honestly believed we had induced our plurality. We never actually spent much time in tulpa communities so never used the words host and tulpa, but we really believed we had created our plurality. Lucia started exploring our plurality with the understanding that anyone they “created” would be an equal and would have equal rights to the body. We did this with the understanding that our system would exist so that everyone in system could love and protect and care for each other. This was the basis upon which we “induced” our plurality. It has been a wonderful experience and everyone cooperates incredibly.
From this perspective, we were able to explore our plurality from a position of strength. We were able to discover several system members and to build communication and trust. We were able to learn from the other systems we were around and draw from their experiences. We were able to explore our innerworld and interact with each other and enjoy our time together. All this put us in a much better position to deal with our trauma when we discovered it towards the end of 2014. We had a good understanding of our system, were able to work together well, and also had a strong support network of other systems who were by our side to guide us through the process.
When we first discovered our plurality, we were not in a position where we could have dealt with our trauma. The simple existence of the tulpa community and the knowledge it gave that singlets could induce plurality were essential to us being able to explore our plurality separately from our trauma. Without that, it’s entirely possible the first we would have known about our plurality was when a therapist told us we had DID. This would have come at a time when we were highly symptomatic and doing badly, a position where we would have been least able to handle it. Instead, we were able to explore our plurality on our own terms with a whole community behind us guiding us along the way.
The idea that it is possible and even desirable in some cases to induce plurality is what allowed us to explore our plurality in this way. Even though we later realized we are a trauma induced system with DID, trying to, then believing we had induced plurality allowed us to explore our plurality from a supreme position of strength. For this, we are incredibly grateful for the existence of the tulpa community.