A Support Role Taxonomy

Close-up of a life preserver.
Photo by Jametlene Reskp on Unsplash

A universal human dilemma: you need social support, but the type of support you need isn’t the type you’re getting.

You just want to vent, but your partner jumps in with advice. A sick person gets tons of gifts, but all they really want is someone to come over and spend time with them while they’re stuck in bed. Everyone wants to come hold the newborn baby, but nobody’s offering to do the parent’s laundry or make some meals for them.

This is complicated by the fact that most people find it difficult to articulate exactly what they need in terms of support, especially when they’re already in a rough spot. Even if they do know, and could verbalize it, many people feel like they shouldn’t look a gift horse in the mouth. So, sure, you don’t need all those nauseating frozen meals while you’re dealing with chemo, but at least they were nice enough to think of you, right?

It can help to learn how to identify what it is that you do need and how to communicate that to people. On the flip side, it can also help to learn which types of support you’re best suited to providing and look for opportunities to do those things—as well as to be careful not to push those types of support onto people who don’t need or want them.

This article is a taxonomy of different types of support that people might need. There are probably many more, although just about anything I can think of fits into one or more of these types. Some are subtypes of each other–advocacy is a type of assistance; perspective could be considered a type of information.

There are three major types of social support. Emotional support involves directly creating space for the person’s feelings and helping them to express or process them. It includes validation, affirmation, comfort, and perspective.

Intellectual support requires using your knowledge and critical thinking to help the person find ways to move forward. You can offer it through information, advice, feedback, or motivation.

Practical support helps people set up their lives and environments in ways that promote coping and healing, and is an ideal way to help if you struggle with emotional labor, listening, or other interpersonal skills. You can provide practical support by giving resources or assistance, supplying distractions, or simply being physically present.

Here are the twelve support roles, broken down in detail. They’re in order (roughly) from least involved and complex, to most.


1. Presence

Presence is the gift of intentional togetherness—the simplest way of “being there.” When you’re present with someone, you are physically[1] there with them. Even if you’re both doing your own separate activities, the person you’re supporting knows that you will shift your focus to them if they need it.

You may need presence if: You just don’t want to be alone.

Ways to be present with someone: Sit with or near the person. Don’t check your phone or start doing other things until they do, and stop if they stop. If they aren’t speaking, resist the urge to fill the silence with talking.

2. Distraction

When the person who needs support isn’t ready yet to actively resolve their problem, or there isn’t a realistic way to resolve it right now, you can help them distract themselves so that they can have a few hours of relief from what’s troubling them. Your main role here is to be the one who suggests the distractions and obtains or sets them up.

You may need distraction if: Focusing on the problem at hand is doing more harm than good; you can’t keep yourself from ruminating and feeling even worse; there’s no practical or effective way to resolve the issue right now, and you just need to get through the next hour(s).

Ways to provide distraction: Take the person out to do something they enjoy. Come over and watch TV or movies together. Talk to them about your own life or tell funny stories. Play games together. Let them play with your pet.

3. Comfort

When two people have an attachment bond, they can comfort each other—a social process that actually reduces the body’s physiological stress response. [2] (Remember oxytocin from all that fear-mongering about casual sex? This [among other things] is what it’s really for.) Comfort can involve touch or words, but the words are just there to make those bodily changes happen. People don’t have to be sexual/romantic partners to be able to comfort each other this way—these types of bonds are common between family members (even adults) and close friends, as long as those relationships are healthy and consensual.

You may need comfort if: You feel unsafe or scared, and there’s someone you trust to reassure you.

Ways to comfort someone: Hug, cuddle, or hold hands with the person (with their consent). Reassure them verbally that everything will be okay, that you’re here, that they’re safe. Keep repeating any words or phrases they find soothing. It’s okay to be repetitive—this isn’t about conveying information to them, it’s about facilitating a physiological response. Give them your full attention, or it won’t work.

4. Validation

Validation is often the first and most important significant process that occurs in therapy. [3] It’s important in other types of relationships as well. When going through difficult times, almost everyone struggles on some level with feeling like their thoughts or feelings don’t make sense or aren’t reasonable or proportional to the situation. For whatever reason, humans can’t really start to heal until we start to understand that it’s completely okay to feel and think as we do. If you’re finding that your attempts to support others fall flat, it may be because they needed validation first, and you skipped over this step. [4]

You may need validation if: You’re struggling with feeling like your experience isn’t real, visible, recognized by others, or “that bad”; you have people actually telling you that it’s not “that bad”; you feel ashamed of your own thoughts or feelings; you worry that you’re being “overdramatic” or irrational.

Ways to provide validation: Listen. Verbally acknowledge what you’re heard. (“I hear you.” “I’m still listening.”) Remind the person that it’s okay to feel the way they do. Reiterate that what they’re saying makes sense to you; if it doesn’t, ask open-ended questions until it does.

5. Affirmation

Closely related to validation, affirmation is the process of helping someone feel that you like them and think well of them. Just as people typically need to feel that their internal experiences are valid, they also tend to cope and heal better when they are reassured that the people close to them still respect them and want relationship with them. It may seem irrational, but I think it has to do with how fundamental our need for social connection is.

You may need affirmation if: You feel diminished or beaten down by your experience; you worry that people think less of you because of it; you’re receiving lots of negative feedback or criticism.

Ways to affirm someone: Tell the person why you admire or respect them. Compliment them. Give them genuine positive feedback about how they’re coping with the situation.

6. Resources

Sometimes, throwing money and/or stuff at the problem really does help. The prevalence of crowdfunding campaigns online is a testament to this. If you can afford it, supporting someone with resources can make a huge difference.

You may resources if: You’re faced with a financial crisis you can’t handle alone; there are tangible things you don’t have and can’t find or afford that would help; dealing with your situation has left you without money to spend on small pleasures or self-care that would help you cope and heal.

Ways to provide resources: Donate/contribute money. Ask what they need and buy it for them.

7. Assistance

If you don’t necessarily feel up to supporting someone emotionally, don’t forget the importance of practical assistance. It’s common to offer this when someone is going through a serious physical illness or has recently had a baby or lost a loved one, but people need it in all kinds of situations. Mental illness or stress can make it difficult to do basic “adulting” tasks, and helping someone with basics like food and laundry can free up time and energy for them to resolve whatever they’re going through.

You may need assistance if: An illness or disability is making it difficult or impossible for you to do something that needs done on your own; managing your current situation is taking up so much time you can’t do other necessary things like cooking, housecleaning, etc.; you lack transportation; you’re concerned about caring for your children or pets while you deal with things.

Ways to assist someone: Ask the person (or someone closer to them) what you can do for or with them. Offer rides, household help, childcare, petsitting, or other types of practical help. Identify what your skills are when it comes to helping people: Are you handy around the house? Great with kids? Skilled at making nutritious frozen meals? Let the person know that you are available to do this thing for them, preferably in writing so they have an easier time remembering to reach out to you if they decide they need it.

7. Information

Information is an often-overlooked form of support, perhaps because it doesn’t seem like a social process. But it is—even if you get it from a book or from the internet, you’re still receiving it from someone, hopefully someone you trust. Some people are very resourceful and tend to quickly learn what they need to know. They may not even realize that information is a specific type of support someone else might need. Others struggle with resourcefulness, and may not realize that they’re missing information, or that someone trustworthy may be able to provide it. Some people have been resourceful their whole lives and flounder when a crisis they’ve never faced before makes them suddenly incapable of finding the knowledge they need.

You may need information if: You don’t understand the facts of what’s going on; you’re feeling stuck because you don’t know enough to feel confident that you’re making a good decision; you feel like there’s nothing that can be done in your situation; you have a serious medical condition that your doctor didn’t adequately explain; you’re facing a situation that involves legal issues, financial decisions, or other specialized knowledge that you don’t have.

Ways to provide information: Suggest books, articles, or other educational materials. Recommend a doctor, lawyer, accountant, therapist, or other professional that you trust. If you specialize in this issue, donate some of your time to provide some education around the issue (within the boundaries of your professional ethics, of course.)

8. Advice

Advice is without a doubt the most-given and least-wanted form of support, which is something we have to acknowledge before we can even talk about helpful advice. While it’s almost always a good idea to get consent before offering support, advice is one of the most important types of support to never give if it’s not asked for. Unsolicited advice isn’t just useless much of the time; it also tends to directly interfere with other vital support processes, such as validation and affirmation. Nevertheless, people do often want advice—they just tend to want it from specific people, and only when those people have the context they need to give advice that’s actually useful.

You may need advice if: you want to know how other people would handle the situation if they were in your shoes; you want to hear from someone else who’s been through this.

Ways to give advice: Ask first! Consider how you’d handle the situation, but take the person’s own needs and values into account. Ask what they’ve already tried or considered, and why it didn’t or wouldn’t work. Make sure you have all the information you need to give helpful advice.

9. Motivation

There are many things that can mess with our executive function—ongoing conditions like ADHD or autism, situational factors like sleep deprivation, long-term emotional states like grief or stress, or simply having way too much to do. Internal motivation is one of the main executive functions, and often one of the first to go. Thankfully, motivating each other is something we can easily learn how to do.

You may need motivation if: You have the capability to do what you need to do, but can’t seem to get started; anxiety, perfectionism, or depression are getting in the way or resolving your issue; you need someone to hold you accountable.

Ways to motivate someone: Check in with the person about the things they’ve said they’d do. Offer encouragement and positive reinforcement. Ask helpful questions (“What would be the next step?” “What’s keeping you from doing that?”).

10. Feedback

Sometimes people need a more involved version of advice or motivation—that’s feedback. Note that sometimes people want constructive criticism specifically, and other times they may only want “negative” feedback if you see something actively wrong with what they’re thinking or doing. It’s the difference between “Do you think I handled this wrong?” and “How could I handle this better?”

You may need feedback if: You’re not sure if you handled a tricky situation appropriately; you’re not sure if you’re interpreting something correctly; you want constructive criticism.

Ways to provide feedback: Point out the person’s strengths or what they’re doing well. Offer suggestions for improvement, or alternate interpretations of a situation. Ask useful questions (“What’s your goal here?” “What other options are you considering?”)

11. Advocacy

Advocacy is a very special type of assistance that involves using privilege, social skills, or knowledge that someone else doesn’t have in order to communicate on their behalf. This usually comes up when someone needs something from some sort of institution or authority figure, but it can also apply to mediating an interpersonal issue or backing someone up when they set a boundary.

You may need advocacy if: You need something from a person or institution and don’t feel empowered to try to ask for it; you feel that it might help to have someone (perhaps someone with more privilege or with skills you don’t have) in your corner.

Ways to advocate for someone: Accompany the person to appointments and help them express themselves effectively. Make sure they are being understood. Resolve an interpersonal issue on their behalf, or serve as a mediator. Obtain their consent to speak to their doctor, therapist, or insurance company to appeal a decision or provide collateral information.

12. Perspective

One of the rarest and most precious gifts you can offer to someone who is suffering is perspective. Like advice, this one is offered much more often than it’s actually available to give, and that’s because many people don’t have as much perspective, or as useful of one, as they think. Perspective isn’t “it could be worse” or “I’ve suffered worse.” Perspective never minimizes the problem; if anything, it shines a clarifying light on it. It can come from a religious or spiritual approach, but doesn’t have to. It can also be thought of as wisdom.

You may need perspective if: You feel lost or hopeless. You have no idea how anyone could get through this. You need someone’s wisdom.

Ways to provide perspective: Make sure you actually have perspective to offer on this issue. (Have you been through something similar? Are you knowledgeable in the person’s faith tradition?) Share an empowering, comforting, or personally meaningful way of looking at the issue. If appropriate, provide a religious, spiritual, or secular interpretation. Use perspective-finding tools that the person values, such as a tarot reading. Recommend a work of art, a book, or an essay that offers wisdom. Perspective is not the same as advice, and does not necessarily include any guidance on what the person should do. It’s more about providing a new lens for them to look through if they want to.


It’s a good idea to explicitly make sure you know what the person wants before providing any type of support. This is especially important with comfort, resources, assistance, information, advice, feedback, and advocacy, as these things are the most likely to cross boundaries when they’re unsolicited. But any type of support can come across as invalidating, tactless, or even violating if it’s not wanted. Nonconsensual touch that’s meant to be “comforting” can be actively harmful.

I’ll break down some of the more complex support roles in later articles. For now, I hope this taxonomy helps you give and receive support to others.


[1] Sometimes presence can be virtual, as when people hang out together via video call or have an ongoing text chat that they know they can use at any time. But it’s much harder to demonstrate presence without a face-to-face (or side-by-side) connection.

[2] https://www.sciencedirect.com/science/article/pii/S0306453013002369

[3] https://www.miriammogilevsky.me/blog/2018/8/21/what-is-therapy

[4] https://the-orbit.net/brutereason/2015/06/29/dont-tell-people-how-not-to-feel/


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A Support Role Taxonomy
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Back Through the Fire

Smoke after a forest fire.
Photo by Joanne Francis on Unsplash

[Content note: cancer, illness, suicide]

In November, I had my last cancer-related surgery. My temporary tissue expanders were replaced with permanent breast implants, and I was instructed to give my body six weeks to recover, after which I could return to my usual activities.

After five weeks and 6 days, I gave in and started exercising. It was almost the New Year. It was deep winter, a time of planning and setting things in motion. I was finally done with treatment, and I was ready to live again.

So for the next six weeks, I lived. I worked out almost daily. I started my private practice. I made plans. I designed a backyard garden. I took classes, learned new things. I took on new roles at work. I returned to freelance writing.

For six weeks, I lived. I was determined to get back everything I’d lost to cancer, and then some. I enjoyed my time with family, unburdened at last by the demands of treatment or recovery. Having emerged unburnt from the fire, I felt that nothing could stand in my way.

For six weeks I lived like a person reborn. This lasted until February 13.

That day my mom told me she had cancer too. That day, my newfound momentum sent me clear off what I now realized was a cliff, and like the coyote in the cartoon, I looked down and found myself unmoored, unsafe, and spiraling down.

It was nothing like my own diagnosis, first of all. I never thought that “I’m thankful for the way I was diagnosed with cancer” would be a set of words my brain would assemble in that order. But I am. I got the call one day. I saw an oncologist the following day. Within a week, I had a clear diagnosis, a treatment plan, a second opinion confirming those things, and a team of medical professionals I trusted.

This was about as different from that as it could get. For starters, the initial “diagnosis”–the one my mom called me about on February 13–wasn’t even that. It was unfounded speculation from a rude, shaming primary care doctor. I let myself believe for a bit that it wasn’t true. But for the next six weeks, as my mom was bounced around between doctors, hospitals, and scan machines like a dented ping pong ball, the picture continually came into focus, then blurred again.

One day it was early-stage lymphoma. Another it was metastatic ovarian cancer. Some days, other diagnoses were thrown out like beanbags on a cornhole board–lung, stomach, liver, breast, uterine. Doctors would walk out of her exam room completely confident and optimistic, only to return subdued and humbled, their hypotheses disproven, without any others waiting in the wings to be tested.

Picture yourself surviving the worst thing you can imagine, and before your scars–literal ones, in my case–have even fully healed, that same thing happens to the person you love most. That was me.

My mom had always been the person I called when I was so desperately upset I couldn’t do anything else. Now I had lost even that. My parents, through no fault of their own, relied on me in completely unsustainable ways during that time. I found myself supporting both of them, trying to curb my spiraling panic whenever they talked about metastasis and preparing for the worst, comforting all three of my siblings (especially the two teenage ones), fielding calls from extended family and close family friends, driving an hour to question doctors at the hospital while sick with the flu, researching–always, always researching–calling and begging my oncologist to take on her case or make a referral, talking my mom down from panic attacks over the phone, using my own therapy appointments to try to figure out how to live if my mom dies.

I could’ve handled this for a week. Maybe two. The mind goes into crisis mode and you somehow push on.

But it lasted for six. By the third week, I was coming apart. I started to become paranoid almost to the point of delusion, refusing to believe anything any doctor said because so many of them had been wrong. When my mom finally had a vague diagnosis and some semblance of a treatment plan, my mind rebelled against it, refused to accept it, and I ranted like an unhinged person over the phone about how this was wrong, and they hadn’t done this or that test or ruled out this or that possibility, and they needed to find a “real” doctor and get another opinion.

To their credit, they did get more opinions. The opinions all converged on the fact that the particular way my mom’s cancer had played out was so statistically improbable that it had only been recorded 20 times in medical history.

By way of comparison, there have been 23.2 million cases of cancer recorded historically in the United States alone.

This broke my brain.

I walked through the world like a fading ghost. Everything was a reminder of the thing I couldn’t forget anyway. The lemon tree my parents gave me as an engagement gift right before my surgery had unceremoniously dropped its leaves over the winter–they do that–and I couldn’t shake the fear that I was killing the last tangible symbol of her love I would ever get. All of my clients suddenly turned out to have dead or dying mothers that they needed to talk about.

My work suffered–everybody noticed. My parents were often calling and texting me during the workday and I would grasp at whatever few minutes I had between appointments to talk to them, sob inconsolably on the floor of my office, or both. I no longer wanted to be alive whatsoever, but even stronger than that feeling was the belief that I absolutely could not die, accidentally or on purpose, without dooming my family for good. By then I was living only for other people–my family, my partners, my clients–and I was starting to fail every single one of them, noticeably and repeatedly. The more I failed, the more I hated myself, my life, and the world.

It was, in short, a complete fucking living nightmare.

You have to understand—I was never one of those people who wonder Why me? when they get sick. Totally reasonable reaction—just not mine. In some ways this is because I incorporate and adapt to new knowledge quickly, and I was immediately focused on survival.

But the other half of it has to do with the way in which having cancer stripped me bare. I discovered that all of that emotional baggage and maladaptation I thought I’d handled years ago were actually still there, dormant. As all of my learned coping skills and cognitive strategies were eroded away like layers of sediment, I found that there was no bedrock of self-love underneath, no protective sense of my own worth as a person.

And so I didn’t feel the need to wonder what I did to “deserve” getting cancer. I didn’t think I deserved it, but I also didn’t think I’d done anything to deserve a happy, healthy life, either. Honestly, getting cancer kind of made sense. On my worst days I really do hate myself enough to make renegade killer cells an apt (if heavy-handed) metaphor.

My mom’s illness was completely different. As the weeks leading up to the eventual beginning of her treatment wore on and on, I hated the world more and more, and wanted to live in it less and less. I wished an asteroid would hit and destroy it. I wanted nothing to do with a world in which something like that could happen to someone like her. I wanted nothing to do with a life without her in it.

As a patient, I had a dark source of comfort—this too shall pass. You either survive cancer or you die.

I survived. My illness taught me that I can overcome anything. My mom’s taught me that no matter what I overcome, the suffering it brings will never end.

And yet. With something approaching an actual working diagnosis, my mom started her treatment in late March. The treatment seemed to be effective. The tumors shrank. I found myself sometimes thinking about something other than her. Spring came, as it always does, and the seeds went into the ground, and my wondrous garden sprang up once again as if from nothing.

And, just like last year, the new life in my backyard brought life back into me, too.

I don’t know what will happen with her treatment, or the rest of her life. There are reasons for hope and there are reasons for despair. Which one will win out in my mind in any given moment is a coin flip. I still haven’t figured out why or how to live without her if she dies. When she dies, as that’s obviously going to happen eventually. That’s another one of those things I didn’t expect to be thinking about this much at my age.

I haven’t written about this for months, except for scribbled ranting in my journal, because I had nothing to say. I could find no meaning or narrative in it. With my own cancer I learned things, experienced things. I had things to say about fear and bodies and friendship and family and work and joy. It was awful but it was also in many ways profound.

This was nothing. I learned nothing, saw nothing. “What am I supposed to write about?” I remember asking my therapist. “There’s no ‘there’ there. I just don’t want my mom to die. I’m just miserable and terrified and grieving already about that. That’s literally it.”

“You should think about why this happened to you,” my mom’s first doctor said, after ordering CT scans. I have also thought about why this happened to me, to us, as has she. We got nothing.

When I lost the thread of my own story last year, even that became part of the story itself. It was a gap, but the gap spoke volumes. When my mom got sick, I wasn’t weaving the web anymore. I was a fly trapped in it.

So I made do with what I have, and made myself a little cocoon from the fibers.

Then, midway through her treatment, everything changed again. She finally got her genetic test results back. She has BRCA-1, the same genetic condition I have. Then I understood.

She was always going to get cancer. It has always been a near-certainty, since long before I was even born, since before she watched her own father survive cancer.

My dad called and told me, and asked me to be the one to tell her. I froze. Couldn’t do it. On the one hand, it was “good” news, of a sort–it was a medical explanation, and it increases her chances of survival because it makes certain additional treatments possible. On the other hand, I shuddered to think of anyone, let alone someone I love so much, going through the hell I went through. What do I say to someone about to go through what was my worst trauma?

I told my dad this. He said, “It won’t be anything like that. We have your experience to guide us.”

And that’s when everything clicked for me at last.

My mom, like me, was always going to end up in this situation. Statistically, it was much more likely that she would go through it first, and I would go second. But that’s not how it happened, thank god, because this way it was my body and sanity on the line, not hers. Because this way I was the one to be mistreated and traumatized like that, I was the one who learned what I learned, I was the one who had to figure out how to demand humane treatment and pain control, I was the one who realized that panic attacks interact uniquely with this particular kind of post-op pain, I was the one who lived to write about it, I was the one who made it my mission to learn how to talk so doctors will listen and to start to teach that to others.

Now none of that will happen to her, so help me god, because I will be for her what nobody was able to be for me.

And with that came the realization that if I had a choice—if I could’ve somehow chosen to be put through this first so that she may survive it with fewer psychological scars—I would’ve chosen this, because I would do absolutely anything to save her life and her happiness, even face down death myself.

Everyone hopes on some level to find some sort of ultimate meaning in the horrors they go through; my answer to that basically got handed to me. I went through it so she wouldn’t have to, so that I could one day walk right back through the fire I’d escaped, and lead her out with me.

Things became somehow easier after that. While there isn’t any sort of cosmic meaning or significance to all this, I don’t really need there to be. In the unanswerable question of her tragedy, I found an unquestionable answer I didn’t know I was looking for.

After that I did something I didn’t expect to do. It won’t seem like a big deal to anyone but me, but I know what it means.

What I did was I bought trees. Berry trees. Black currant, gooseberry, cornelian-cherry dogwood, lingonberry, hawthorn, fig, mulberry, and, of course, rosa rugosa, which produces those rosehips my mom so prizes.

For the first time I was willing to plant things that wouldn’t give fruit for at least a year if not more, and to trust that on the day they repay all of my digging, watering, fertilizing, pruning, and protecting for the first time, I will still be around, and I will still care. That one beautiful fall day, maybe one of the last, my mom will visit me, and she will steal rosehips from my bushes, telling me that I wouldn’t use them anyway, and her laughter will be strong enough to send the birds from the feeders and bushes, flocking up, up into the dying light.

So that’s where I was, last weekend, digging holes in the yard as the rising summer sun woke up and thawed me.

On the patio behind me, where I’d set it out after the last frost, my parents’ lemon tree was waking too, sending bursts of new smooth green leaves from its buds like offerings to the sun god it worships.

I finished my work, picked fresh herbs from the garden for my mom, threw my stuff in the car, and drove west to Dayton, where my family was waiting for me.


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Back Through the Fire

Speaking Gently to My Body

I’ve always criticized what I’ve sometimes called the chocolate-and-bubble-baths model of self-care, where a series of supposedly “pampering” actions is supposed to somehow replenish you and make you ready to face the world again.

But I think I’ve found the usefulness of these types of activities, and the answer, as usual, lies in mindfulness and intentionality rather than escapism and consumerism.

I used to have a lot of body image issues, and then I found feminism and did a lot of personal work and (I thought) resolved them. Then cancer hit and a lot of that work completely undid itself. Suddenly I was standing in front of the mirror saying shit to myself that I hadn’t said for a decade. That was weird.

But by 2019 my body and I had arrived at a sort of uneasy truce, held together by 1) it not having cancer and 2) me practicing intuitive eating and engaging in regular movement that feels good to me.

And then I got a severe flu, went to urgent care, was not diagnosed with the severe bacterial infection I also coincidentally had, and ended up hospitalized for two days on a near-constant drip of IV antibiotics.

If getting hospitalized for two days due to medical mismanagement isn’t perhaps the most on-brand thing that can happen to me at this point, I don’t know what is. I mean, it’s not like I’m writing a book about that or anything.

That said, the other really on-brand thing that happened was that I rallied and got discharged from the hospital just in time to get a good night’s sleep, keep my travel plans, and hop on a plane to Austin, where I’m now typing this in a backyard wearing nothing but leggings and a tank top. (I deserve this.)

But before all that, I was home from the hospital in a shitty mood with barely enough energy to stand up without something to support me. I also needed a shower. I’ve now done it several times and if you haven’t experienced this, I can absolutely assure you, the post-hospital shower is the best shower you will ever take in your life. It beats post-camping showers. It beats “the landlord finally fixed the sputtering showerhead” showers.

In the shower, I shampooed my hair, used two different kinds of conditioner, and used both body wash and scrub to exfoliate my severely-neglected skin. When I got tired, I sat down on the floor of the shower and let it wash the conditioner out of my hair.

When I felt ready to be done, I grabbed a towel from the towel warmer (I should mention, this was at my parents’ house, by no means do I personally own a towel warmer) and slid the shower door shut again so I could dry off in the remaining warmth.

I noticed that I felt compelled to dry myself more gently than I usually do. Of course this was probably in part because of my recent infection, but that had only affected a small part of my body. I realized I wanted to pamper myself—not in the mindless sense of showering the body in fancy products or putting it through a particular set of actions (no shame if you enjoy mani-pedis, but to me they are painful and awful and I have no idea how that came to abstractly represent self-care for anybody who does not enjoy pain), but by treating it with the sort of gentleness I would treat a loved one returned from the hospital.

After I finished drying off, I found myself saying, “Now, my dear, you are good as new.” I continued: “Thank you for everything you’ve done for me. You fought hard and you won.”

Then I started tearing up.

Then I left the shower and started asking myself why I never thought to speak to my body this way after (let alone during) cancer.

I mean, if what I said was true in this situation—and it certainly felt true—how the fuck isn’t it even more true for the process of going into remission from cancer, regrowing my hair, losing the bloat and swollenness of chemo and steroids, and healing my surgical scars?

The truth is, as miserable as it was to suffer through both a viral and a bacterial infection at the same time—and it was literally worse than chemo, by the way—I didn’t hold it against my body that it happened. It wasn’t something my body “put me through.” It was something we got put through together. I felt awful when I was sick and I felt awful for my poor body. My fever spiked to 105 at times. Almost my entire face turned red and swollen. My lymph nodes ballooned. My head hurt so much I could barely find a way to set it down on the pillow so I could sleep. After my dad made me drink TheraFlu one night, my body violently rejected it into the toilet. (Kids: do not have TheraFlu be the only thing you consume all day, unless you’d like to use it to expel an accidentally-injested poison.) It was just an awful six-day slog of fucking misery.

And I didn’t blame my body for it at all.

I could’ve—immune system failure and whatnot. But I didn’t.

Cancer and surgical trauma felt entirely different. Cancer seemed personal and internal two times over—once because it involved my flawed genes, once because it involved my own rogue cells. After surgery, my muscles seemed to attack me and nobody listened to me.

This time, nobody denied that I was sick and hurting. I felt able to complain, to lie in bed and moan, to seek emotional and medical help. (Half-assed as the latter was at times.) With surgery, my medical care was absolutely top-notch, but that and practical assistance were pretty much the only forms of support I had.

As it turns out, it’s much easier to not to blame your body when your non-physical needs are being heard. It’s easier to care for and even move toward loving your body when you feel fully cared for and loved by others.


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Speaking Gently to My Body

My Zine, “The Girl Survives Cancer in This One,” is Now Available!

Banner for "The Girl Survives Cancer in This One." Visit bit.ly/GirlSurvives

As you may know, I’ve been writing a book of essays about my experience as a breast cancer survivor. Last month, I decided to publish a zine that collects some of the essays I’ve written so far, to put my writing out there and build some interest in my book.

It ended up being a very fun project (my first zine!) and although I didn’t end up with the old-school photo-copied look I originally planned on, it’s very pretty and the writing is very much the focus.

A photo of the inside of my zine.

It’s now available on Etsy in digital format for $4, and as a paperback for $8. You can even get the paperback signed! Who knows, maybe it’ll be worth something one day.

If you want to get updates on my book as it progresses, you should subscribe to my newsletter here.

I hope many of y’all buy it and read it, and don’t forget to leave a review on Etsy!

A photo of the cover of my zine.

My Zine, “The Girl Survives Cancer in This One,” is Now Available!

Building Blocks of Mental Distress: A Dimensional Assessment of Mental Illness

This is a cross-post from my professional blog, where the most updated version of this will be.

The field of mental healthcare has its roots in medicine. The earliest mental health professionals were doctors—psychiatrists. Like medicine, psychiatry and clinical psychology are based on the process of assessing patients’ symptoms, performing some sort of test if needed, assigning a diagnosis, and creating a treatment plan based on that diagnosis.

This is a very sensible approach for most medical issues. If I appear at my primary care doctor’s office complaining of persistent headaches, she shouldn’t just treat the headache by prescribing a painkiller. She should refer me to someone who can figure out what’s causing the headache, and then treat that condition, whether it’s extreme stress, a head injury, a bacterial infection, a brain tumor, or some other problem.

Even though we’ve been treating mental health issues this way for at least a century, it’s not the best way to treat them. And many psychiatrists, therapists, and researchers are starting to realize that.

That’s why we’re finally starting to see approaches to assessment and treatment of mental illness that move away from the much-argued-about diagnoses in the DSM, and sometimes away from the concept of mental illness altogether. Psychologists such as David Barlow, Rochelle Frank, and Joan Davidson have been working on so-called transdiagnostic approaches[1]; the newest edition of the DSM includes a chapter about a proposed new way to diagnose personality disorders that’s based on specific personality traits rather than broad, stigmatized labels[2].

I’m looking forward to the day when the field as a whole has shifted to these types of approaches entirely. For now, I needed a tool I can use with clients to help them (and myself) understand what they’re dealing with and access helpful resources and support. So I created my own informal dimensional assessment.

This assessment is a list of 33 (and counting, I’m sure) ways in which our brains can get in our way. You could think of them as symptoms, but I prefer to think of them as painful patterns, or building blocks of mental distress. Everyone has at least some of these; many people have a lot of them and don’t necessarily suffer greatly for it. It’s all a matter of degree.

Most of these terms are actual mental illness symptoms that appear in the DSM or in other clinical psychology texts. Some of them I coined from existing words because they aren’t really being talked about very much yet. Each of them shows up commonly with at least one established diagnosis, and most relate to quite a few of them.

In creating this list, it was important to me to try to get at the ways in which people who aren’t therapists or scientists might actually think of these experiences. So each building block has a statement with it. The way I plan to use this clinically is to show clients a list of the statements and ask them to rate each one on how much they agree or disagree with it. That would give both of us a sense of what their psychological landscape looks like, regardless of which DSM diagnoses it might resemble.

The initial feedback I’ve gotten is that folks find this really helpful for communicating with their therapists and psychiatrists about what they’re dealing with. I think that’s a great way to use this tool. Therapists know specific interventions that target many of these things; coming to a session and saying that you’d like to address your amotivation, emotional disregulation, and tendency to ruminate is bound to be more helpful than just saying that you want to be less depressed.

  • Agitation: “I often feel so on edge that I need to be moving constantly, as if I want to crawl out of my skin.”
  • Amotivation: “I struggle with getting myself to actually do things, even when I want or need to.”
  • Anhedonia: “I don’t get any joy out of things I used to like.”
  • Attention disregulation: “I can’t seem to choose when to stop or start paying attention to something.”
  • Avoidance: “I find myself trying to avoid things that bring up painful thoughts or feelings.”
  • Cognitive inflexibility: “When things don’t go the way I wanted or planned, it’s very difficult for me to adjust my expectations or make a new plan.”
  • Compulsiveness: “Sometimes I feel like I need to do an action or ritual in order to feel okay, and I feel awful if I try to force myself not to.”
  • Depersonalization: “Sometimes I feel like I’m not really in my body, or I don’t know who I am.”
  • Disordered eating: “I have a hard time controlling what or how much I eat; or, I need to control it so carefully that it’s hurting me.”
  • Dissociation: “Sometimes I experience a memory so strongly that I’m not sure who, where, or when I am.”
  • Distress intolerance: “I don’t feel like I can handle strong emotions. I need to make them go away.”
  • Dysmorphia: “I seem to see my body differently than other people do.”
  • Emotional disregulation: “When I have strong emotions, it’s very difficult for me to manage them and calm myself down.”
  • Emotional lability: “My mood can change quickly between extremes.”
  • General anxiety: “I often think about things that could go wrong in the future.”
  • Guilt: “I feel guilty even when I didn’t do anything wrong.”
  • Helplessness: “I don’t really believe that there’s much I can do to help myself feel better or improve my life.”
  • Hopelessness: “I feel like things won’t turn out okay.”
  • Hyperactivity: “Having to sit still and not move makes me extremely uncomfortable.”
  • Hypervigilance: “I’m always on the lookout for possible danger, and often I sense danger where there isn’t any.”
  • Identity disturbance: “I don’t have a strong sense of who I am; it depends mostly on the opinions of the people around me at the time.”
  • Impulsivity: “Sometimes I say or do things without thinking about them first, and afterward I can’t always tell you why I did them. When I have an urge to do something, it’s very difficult to keep myself from doing it.”
  • Inattention: “I can’t make myself focus on things I need to do.”
  • Irritability: “Little things annoy me so much I want to yell or snap at people.”
  • Mania: “I have periods of time during which I feel extremely energetic, irritable, or ‘high,’ and during these periods I tend to sleep little, talk too fast, accomplish a lot of things, or do things I later regret.”
  • Obsessiveness: “I have intrusive thoughts that bother me and I can’t make them stop.”
  • Panic: “Sometimes, my breathing speeds up and my heart starts rushing, and I feel like I’m going to die.”
  • Psychosis: “I perceive or believe things that feel very true to me, but aren’t true according to everyone else.”
  • Rejection sensitivity: “I feel like I can’t deal with it if someone dislikes me, or says no to me. I’m constantly on the lookout for potential rejection, and I probably sometimes see it when it isn’t really there.”
  • Rumination: “When I start thinking about something negative, I tend to keep thinking about it over and over and feeling even worse.”
  • Social anxiety: “When I’m around people, I worry about how I’m coming across or what I should say or do.”
  • Splitting: “I tend to see people either as extremely good or extremely bad, and I can switch quickly from one to the other.”
  • Suicidality: “I have thoughts that I want to die, or that I wish I could just not exist.”

Although I’ll probably never be able to turn this into an Official Research-Verified Published Thing or anything like that, I do hope to keep refining it and making it useful to my clients—and to any other therapists who want to give it a try.


[1] https://www.newharbinger.com/blog/transdiagnostic-psychology-why-we-need-transdiagnostic-road-map

[2] https://www.psychologytoday.com/us/blog/fulfillment-any-age/201303/whats-new-and-old-in-the-dsm-5-personality-disorders


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Building Blocks of Mental Distress: A Dimensional Assessment of Mental Illness

Stuff I Read That You Might Like, Vol. 1

An e-reader with a cup of coffee, a notebook, a pen, and a pair of reading glasses.
Photo by Aliis Sinisalu on Unsplash

For a long time I’ve used Tumblr primarily to share quotes from my favorite articles that I read online (and sometimes books, too). Since I’m no longer using Tumblr due to their atrocious, sex-negative decision about adult content, I haven’t been able to find a better way to do this. Most so-called Tumblr “replacements” are pretty barebones and/or nonfunctional.

So, clunky as it is, I’ll be doing it here! Every so often I’ll post some quotes and links to stuff you might like.

Starting off with a very topical one:

Tumblr made sex a community experience.

—Vex Ashley, “Porn on Tumblr — a eulogy / love letter

Now that the full scope of this administration*’s political vandalism and base criminality is largely being copped to in broad daylight in various federal courthouses, a good chunk of the elite political press is moving into the Hoocoodanode? stage of political journalism. This is best exemplified byThursday’s New York Times podcast, the headline of which—“The Rise of Right-Wing Extremism, and How We Missed It”—got dragged like Hector’s corpse all over the electric Twitter machine until someone at the Times sharpened up and changed the last half of it to “…and How Law Enforcement Ignored It,” which is a little better, but not much.

To take the simplest argument first, “we,” of course, did no such thing, unless “we” is a very limited—and very white—plural pronoun. The violence on the right certainly made itself obvious in Oklahoma City, and at the Atlanta Olympics, and at various gay bars and women’s health clinics, and in Barrett Slepian’s kitchen, and in the hills of North Carolina, where Eric Rudolph stayed on the lam for five years and in which he had stashed 250 pounds of explosives for future escapades.

—Charles P. Piece, “‘We’ Did Not Miss the Rise of Right-Wing Extremism. You Did.

Inspired by online recipe sites, he’d sit down to dinner and then let me know what rating I earned. “If I give you five out of five, you’ll quit,” he joked. And I laughed because when I was in my 20s, I believed that you were supposed to laugh when someone hurt your feelings. I thought you were constantly supposed to be trying harder.

—Lyz Lenz, “Now That I’m Divorced, I’m Never Cooking for a Man Again

“As you become more acclimated to the cold, your body becomes more effective at delivering warm blood to the extremities, your core temperature goes up, and all that contributes to being more resistant to the cold,” Leonard told me.

That means the only cure for hating winter, unfortunately, is just more winter.

—Olga Kazan, “Why So Many People Hate Winter” (ugh.)

Mattis saw it up close. He bore it as long as he could, in hopes of mitigating the damage. But when Trump broke America’s promise to the Syrian Kurds, he stained Mattis’s honor, too. That, apparently, Mattis could not accept. He leaves and takes his honor with him. And now the question for Congress is: The Klaxon is sounding. The system is failing. What will you do?

—David Frum, “No More Excuses

It’s called Star Wars. Not Star Trek, not Star Peace, not Star Friends, not even Star Tales. This gargantuan fictional universe is labeled with a title that guarantees the ability to travel space… and near-constant warfare.

We can debate the relative okay-ness of this focus from a moral standpoint, sure. But in reality, I think that Star Wars is accidentally teaching us the greatest lesson of all: It’s depicting what a universe looks like when you dedicate all of your research and technological advancements to war and destruction, and unwittingly showing us what an incredibly dark place that universe is. Because the Star Wars universe is a fun fictional playground for sure, a great place to build weird and wonderful stories… but it’s not a good place. Not by a longshot.

—Emily Asher-Perrin, “Star Wars is Really a Cautionary Tale About Devoting All Technological Advancements to Death

It’s no longer socially acceptable to believe that women are somehow less than especially not during a time when feminism is wielding so much cultural power. But arguing that women are just naturally better at caretaking or domestic work has become a clever way to shirk living up to progressive values while claiming you are simply complimenting women on their stellar ironing skills.

One way to combat this line of thinking is to highlight how fully capable men are in the private sphere. It is true that American culture relishes in portraying men as dolts when it comes to parenting and cleaning, and it’s an unfair stereotype.

But for women to make real progress in and out of their homes, men must give something up: the backwards dream of holding onto their feminist bona fides while seeking out female partners willing to limit their own aspirations to the home.

—Jessica Valenti, “The ‘Woke’ Men Who Still Want Housewives

So yes, forced birthers and [Status Quo Warriors], if you’re going to play it like that, I am OK with the idea of a world into which you, personally, were never born. I am equally as OK with the idea of a world where I don’t exist, either. Neither you nor I personally matters that much in a universe so vast and a sea of human experiences so rich. You and I both are accidents in our existence, possibly unhappy ones.

I would’ve rather your mother not have been forced to carry a pregnancy she didn’t want to term. I would’ve rather your father had approached your mother respectfully in an appropriate setting, or not at all. I dare to love your mother as a fellow human being more than you do and to dream of a better world for people like her. It’s rank misogyny and not very humanist at all to think otherwise.

—Heina Dadabhoy, “Why I Don’t Care If You Wouldn’t Have Existed

It is maddening to watch adult men respond to revelations of endemic sexual harassment in the workplace by instituting a series of ludicrous personal codes, rather than by learning the relatively straightforward lesson on offer: Don’t sexually assault or harass anyone.

At best, these “rules” are reflective of employers’ woefully incomplete approach to sexual harassment. Employers have long done the absolute minimum to comply with the law, relying on trite videos focused on what you can and cannot say or do in the workplace (“don’t give back rubs” or “don’t offer promotions in exchange for sex”) and sexual harassment policies designed primarily to protect them from lawsuits. The sweeping scale of the Me Too movement makes it clear that no mere set of rules is sufficient to prevent workplace harassment, especially when those rules fail to speak to all of the various power imbalances that make the critical distinctions between genuinely consensual workplace romances and harassment.

—Tahir Duckett, “Avoiding Women At Work Is A Childish, Cowardly Response To #MeToo

When you are terribly afraid of being held responsible for the emotional well-being of others, it feels very mature and responsible to decide that you should “work on yourself.” It becomes both a way of retroactively absolving yourself (wow, can you believe all of the ways my issues manifested before I decided to work on them) and a rather elegant little trick to exonerate ongoing bad behavior (dang, those pesky issues again! I guess I must keep working on them). This is especially true for those too-clever-by-half motherfuckers who think that nobly warning someone in advance they “are working on their issues” mitigates any way in which they might disappoint or harm. And even with the best of intentions, it obviates the fact that relationships themselves are a process of being made ready, not something you come to static and fully formed.

[…] We need each other desperately, in ways none of us can be ready for.

—Brandy Jensen, “Ask A Fuck-Up: I’m still in therapy. Should I be dating?


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Stuff I Read That You Might Like, Vol. 1

Do Not Let Tumblr Frame Their Adult Content Ban as “Positive”

Tumblr is banning all “adult” content. Besides being a terrible business move, this is also one of the most disingenuous decisions I’ve ever seen from an internet company. And I’ve seen a lot.

Yes, the change is happening because the Tumblr app was temporarily removed from the iOS App Store due to child pornography. (The collaborative database Tumblr shares with other companies that’s supposed to filter out probable child porn apparently let some posts through that shouldn’t have been.) Rather than justifying the new policy, though, that just adds insult to injury. In my (very heavily-regulated) field, we have a term for this: CYA.

The disingenuity of Tumblr’s statement starts very early on, when they describe their position on posting child porn: “Let’s first be unequivocal about something that should not be confused with today’s policy change: posting anything that is harmful to minors, including child pornography, is abhorrent and has no place in our community.”

That’s nice, but if you don’t want this policy change to be “confused” with banning child pornography, you might try not instituting it in response to getting criticized for allowing child pornography.

They continue:

We spent considerable time weighing the pros and cons of expression in the community that includes adult content. In doing so, it became clear that without this content we have the opportunity to create a place where more people feel comfortable expressing themselves.

Which people? Who feels “uncomfortable” posting on a site that also allows adult content, and who will be made to feel uncomfortable—or even unsafe—now that this change is happening?

There are no shortage of sites on the internet that feature adult content. We will leave it to them and focus our efforts on creating the most welcoming environment possible for our community.

Are there? I mean, yes, there’s YouPorn and Fetlife and whatnot. These are very different types of websites than Tumblr. While I’m sure sex-friendly alternatives to Tumblr exist, I honestly can’t name any off the top of my head. Given how entrenched I am in internet culture, that suggests that there may well be a “shortage.”

Another thing, filtering this type of content versus say, a political protest with nudity or the statue of David, is not simple at scale. We’re relying on automated tools to identify adult content and humans to help train and keep our systems in check. We know there will be mistakes, but we’ve done our best to create and enforce a policy that acknowledges the breadth of expression we see in the community.

This is perhaps the most honest part of this entire statement, as it at least admits that there’s going to be collateral damage. Except realistically, it won’t be statues of David or even “political protests with nudity.” It will be queer, trans, and non-white individuals sharing their experiences and identities—the exact sorts of people who use Tumblr to “speak freely about topics like art, sex positivity, your relationships, your sexuality, and your personal journey,” as the statement admits.

What this means in practice is that, like Facebook and Instagram, Tumblr’s “automated tools” (along with the biased humans supposed to keep them “in check”) are going to ban photos of breastfeeding mothers, topless photos of trans men, references to menstrual blood, and the like. Many Tumblr users are already testing this, with hilarious but also depressing results.

And on the topic of topless photos. In their definition of “adult content,” the Tumblr team writes: “Adult content primarily includes photos, videos, or GIFs that show real-life human genitals or female-presenting nipples, and any content—including photos, videos, GIFs and illustrations—that depicts sex acts.”

What the fuck are “female-presenting nipples” and why are they less appropriate than “male-presenting nipples”? (What happens with nipples that are evidently nonbinary?)

The definition continues:

Examples of exceptions that are still permitted are exposed female-presenting nipples in connection with breastfeeding, birth or after-birth moments, and health-related situations, such as post-mastectomy or gender confirmation surgery.

Why are “female-presenting nipples” acceptable when it comes to birth or breastfeeding, but not when it comes to just existing on their own, without cancer or surgery?

Once my mastectomy scars heal, they’ll be barely visible, and once I buy fake adhesive nipples, my breasts are going to look extremely realistic (not to mention totally bangin’, but that’s a separate conversation). Say I want to post a photo to reassure other survivors that they are able to get these fantastic results too. Why wouldn’t my photo get flagged and removed?

The difference is pretty obvious. It’s not really about the gender of the nipples’ owners or whether or not they’re laying in a hospital bed. It’s simply this: tits are okay as long as they’re not there to titillate.

To that end, nipples that aren’t “female-presenting” are fine, because the assumption is that they’re not pornographic to anyone—nobody gets off on them. (That’s obviously false.)

What is all this for? What is Tumblr trying to change about the way their platform is used?

One word that keeps coming up in their communications about the change is “positive.” “A better, more positive Tumblr.” “We won’t always get this right, especially in the beginning, but we are determined to make your experience a positive one.”

The word “positive” is doing some interesting work in this statement and I want to unpack that a bit. In what way is a community without (consensual, legal) adult content a more “positive” (or more “welcoming”) community? What is “negative” about the presence of consensual, legal adult content? What is negative about “female-presenting” nipples as opposed to other kinds? Why is a breast uncovered for feeding a baby more “positive” than a breast that’s just hanging out?

The staff writes in their update to the community guidelines that “we do not judge anyone for their desire to post, engage with, or view this stuff,” yet they also say that a space without “this stuff” is “more positive.” What is that if not judgment?

There’s only one neutral word to accurately describe the new Tumblr, and that’s “more child-friendly.” The only reason for removing adult content is to make it (more) possible for children to exist safely in a space. But Tumblr already had a Safe Mode for that reason—a feature that is now being discontinued because it is no longer needed.

“More child-friendly” is not “more positive.” It’s just more child-friendly. And unfortunately, even that can be a loaded term. Many websites, most notably YouTube, have been criticized for removing LGBTQ content in the name of the children, even when the same content would be deemed appropriate if it featured straight, cisgender people.

(As an example, just think about how many people screech “BUT THE CHILDREN” if a same-sex couple cuddles or shares a quick kiss in front of kids. Yet these kids see similar forms of affection between their straight parents all the time. [I mean, judging by how shitty some of these people are at relationships, maybe not.])

Competing access needs are a thing. Yes, a space where people can freely post pornographic content will not be as open to minors, even if there is a Safe Mode. However, children as a group do not seem to be suffering right now for lack of websites to use. But queer and trans people, and sex workers (many of whom rely on Tumblr to make a living), absolutely are. And these are the types of people who have made Tumblr what it is. For example, many people I know used to enthusiastically follow Cliff Pervocracy’s Tumblr, an invaluable resource on consent and sex-positivity. As Cliff pointed out on Twitter, his Tumblr account was already banned even before this change was made.

I get freaking out because you’ve messed up something as serious as banning child pornography from your website. I really do. And I’d be more understanding of this change if the Tumblr team were at least upfront about that.

Instead, they literally come right out and state that a Tumblr without consensual adult content is a “more positive” Tumblr. They conflate consensual adult content with child pornography, which is as offensive as conflating consensual BDSM with violence and consensual sex work with trafficking.

And speaking of conflating sex work with trafficking: this is bigger than Tumblr and it’s bigger than getting kicked out of the iOS App Store. It’s a direct consequence of SESTA/FOSTA, and will probably get worse.

Our society’s irrational and extreme fear of sex is killing people and ruining lives.

But back to Tumblr: unless they reverse this change (unlikely), I’ll be ending my presence there. Whether or not you have a Tumblr account and do the same, here’s my charge to you—do not let anyone get away with framing these types of changes as “positive” or “friendlier” or even “safer.” At best, these changes make spaces more accessible to minors. At worst, they further stigmatize marginalized people and cut them off from community and financial support.

If that’s what we’re doing, let’s at least be honest about it.

Do Not Let Tumblr Frame Their Adult Content Ban as “Positive”

How Big is Your Hard Drive?

Close-up of a hard drive.
This is relevant, I swear.

This is a cross-post from my professional blog.

Some friends and I were talking recently about the concept of “emotionally unavailable” people. Most of us have had a friend—perhaps ourselves—who has tried to date someone who seemed into them, but just wasn’t quite present. Sometimes this type of partner is upfront about their ability to commit and/or be there. Sometimes, they aren’t, and their behavior seems confusing and contradictory. These pseudo-relationships can drag on for years until we are finally able to move on, understanding that however much the person enjoys our presence, they are not interested in making things more committed or structured than they currently are.

If I knew what to do in these situations I’d probably be retiring a millionaire, but I do have an analogy that might be helpful. I thought of it on the spot to give my friend some advice. (If you’ve ever been my client, you know how much I love a good geeky analogy.)

Computers come with different hard drive capacities. If yours doesn’t have enough space for you, you can maybe buy and install a new one—but for the moment, you’re stuck with the one your computer came with. Maybe you can’t afford a new one right now.

Different hard drives also have different things stored on them, and these things take up different amounts of space. I know people whose hard drives pretty much just contain the system files, maybe a few extra apps. These people use their computers mainly to get online. Maybe computers aren’t very important to them and they don’t use them much at all.

Some people have a lot to store—photos, music, videos, complex projects they’re working on. These folks are buying hard drives in capacities I didn’t even know existed. (This year, the world’s largest solid state drive hit 100 terabytes. What are they storing on that hard drive???)

Don’t think of the hard drive as your brain. Those analogies are really reductive, and usually insulting to us humans. The hard drive is a symbol, and it represents something I call your capacity as a person. That encompasses a lot of things—time, energy, physical and mental ability, willpower (which isn’t really a thing, but that’s another article; it’s useful here as a concept), tolerance for uncertainty or negative emotion, and much more. For instance, not everyone has the capacity to be a therapist. Being a therapist requires having a lot of space to hold other people’s pain. Not everyone has enough space for that. Unfortunately, some therapists end up without enough space to hold their loved ones’ pain, or even their own.

Say I have a 1 TB hard drive that’s full of music and photos. Maybe there’s 300 GB left over. Then a friend asks, “Could I put some of my videos on your hard drive? I need somewhere to store them for a while.” I say sure, but then they come over with their external drive and I see that they have an entire terabyte of videos. That’s not going to fit on my hard drive. I could probably store some of their videos, and that might still be helpful for them. But maybe they really needed to store the entire drive’s worth. I don’t have the capacity.

This kind of thing happens in friendships and relationships all the time. You might have a good amount of your own shit to deal with, but that doesn’t mean you can’t listen to your friends vent about their own problems from time to time, or give them advice about a work situation, or treat them to a nice dinner while they’re going through a breakup.

You might not be able to be a friend’s primary source of support as they navigate a serious illness, however. First of all, the time factor would be prohibitive—you may not be able to drive them to all of their medical appointments, be at their house enough to care for them when they can’t care for themselves, and so on. The stress of being a full-time caregiver would be way too much. Holding their anguish as they face the possibility of death or disability is also, well, a lot. Your friend needs more people on their team.

Some people are carrying a lot of trauma, hardship, or personal responsibilities with them already. No matter how large their hard drives happen to be, there may not be space there for you.

Not only that, but some people have pretty small hard drives to begin with. I’ve known many people who just don’t seem to have a lot of space for others in their lives. They don’t tolerate much emotional turbulence when it comes to other people. They may be interested in sex, casual friendship, or even romance, but they don’t have the capacity to build interdependent, long-lasting relationships with others—at least not until they do some work on themselves, and get some bigger hard drives. Some people want to do that work; others are perfectly content as they are.

Here’s where this analogy really breaks down—buying a new hard drive is a million times easier than increasing your capacity for holding other people. And while you can buy a larger hard drive for your friend whose computer you’re always wanting to store your videos on for some reason (this is weird), you cannot increase others’ capacity for them. They have to choose to do it for themselves, and they may not want to. Or it may take them a long time, or they may not be able to do it at all.

If you are hoping for a deeper relationship with someone whose hard drive seems to be too small—or who has way too much data on it already—you have to ask yourself whether or not it’s likely that this person is going to have more space for you anytime soon, and whether or not they want that space to be yours.


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How Big is Your Hard Drive?

Who Decides When Pain is “Intolerable”?

Imagine that, like me, you have a serious, incurable medical condition. If left untreated, this condition could kill you or at least have a devastating, permanent effect on your ability to work, enjoy yourself, and function independently. There is a treatment available, but it’s not totally guaranteed to work. It will probably at least help, but it doesn’t actually cure the condition. It also causes serious side effects and carries high risks of long-term problems. You even might end up needing further treatment to manage the effects of the first treatment.

What do you do?

Here’s another complication—the risky, expensive treatment makes a lot of money for the pharmaceutical companies who produce it. That leads some people to claim that the treatment is a sham and you shouldn’t accept it—instead, you should “learn to live with” the consequences. But your doctors say that despite the risks, this is your best chance of living a full, long life.

Now what do you do?

Well, if the medical condition is cancer and the treatment is chemotherapy, then most people, including me, take their chances with the treatment. Some go into remission. Some don’t, or their disease returns. Many people with stage 4 (or metastatic) cancer that has spread throughout their body are given chemo indefinitely as a way to try to manage and control the cancer for as long as possible.

But what if the condition is severe and incurable chronic pain, and the treatment is opiates?

It’s not a perfect analogy. It’s not supposed to be. But the reason most people recoil instantly at that comparison is because most people don’t see severe chronic pain as an illness in the same way that cancer is. Sure, everyone needs an ibuprofen at some point in their lives, and sometimes if you have a serious surgery you may need Percocet or codeine, but to most people, pain is not in and of itself a medical condition that merits treatment.

People are rightly suspicious of opiates because ever since the days of morphine, pharmaceutical companies have mislabeled opiate medications and mislead the public (and even doctors) about their addictive properties. (That’s one point at which the analogy with cancer and chemo breaks down—as far as I know, we’ve always known that chemo literally destroys the cells in your body.) Doctors used to prescribe opiates without warning patients about the potential for addiction and the importance of taking appropriate doses, tapering down when needed, and complementing the opiates with other, non-addictive methods of pain relief.

However, none of this negates these facts: 1) many people suffer from severe and incurable chronic pain, and 2) opiates are the only drugs that allow some of these patients to achieve anything resembling a livable situation.

Now that politicians are once again yelling at each other about “fixing” the “opioid epidemic,” I’m seeing a lot of pundits and public figures carefully dancing around the inconvenient and messy reality of pain. “How do we get these people to stop abusing opiates?” they moan. “Maybe if we ban doctors from prescribing them.”

They’ll go on to qualify. “We’re not saying nobody should ever get them. But it should be harder to get them, and it should only be for people who really need it.”

You know what that reminds me of? “We’re not saying nobody should be able to get an abortion. But there should be a waiting period, and you should have to hear the baby’s heartbeat, and any doctor performing them should also have admitting privileges at a nearby hospital in case something goes wrong, and definitely not after 20 weeks, and—“

In both cases, the “guidelines” and “restrictions” and “regulations” may seem like they’re there to prevent “abuses of the system” or people getting medical care they don’t really want/will regret later. But really, the goal is pretty clear—sharply reduce the frequency with which this type of medical care is being provided. [1]

And the reason that’s the goal isn’t just because they believe that this type of medical care is harmful to patients. It’s also because they believe that it’s ultimately immoral and harmful to society.

If that wasn’t already painfully (heh) obvious from talking to doctors and politicians about pain management, it’s also obvious when you look at the type of research being done. In a Vox article about the issue, German Lopez cites a study about what happens when doctors are informed when their patients overdose on opiates they prescribed:

The results: Clinicians who got the letters prescribed nearly 10 percent fewer opioids than those who did not receive a letter. The letter-receiving clinicians were also less likely to start patients on opioids and less likely to give patients higher doses of opioids. [2]

This is being presented as a successful outcome. Why? How do we know how exactly these doctors decided whom they were going to deny opiates to? What if some, or most, of the patients who made up that 10% statistic were patients who really needed these medications? How many of those patients might go on to overdose on street drugs that they sought out because of unmanaged pain?

And that’s how we get to opinions like these, from a Vox article by Sarah Kliff, who cites the article above:

But there is one quote in German’s piece that stands out to me the most, from drug policy expert Keith Humphreys: “Something needs to be worked through the culture as well about how pain is part of life. If you’re in excruciating pain, it sucks. And I’ve had pain conditions myself. But not all pain is intolerable or needs to be pushed down to zero with an opioid.”

This, I think, is the hardest part of backing away from opioids: admitting that medicine doesn’t have a perfect cure for pain — that for some patients, zero pain isn’t possible. [3]

Here’s the problem, though. “Not all pain is intolerable” means acknowledging the fact that some pain is intolerable, and any way you slice it, you have people other than the patient determining if their pain is tolerable or not. And not only that, but this decision-maker is essentially serving as a gatekeeper to effective pain-relieving medication, placing them in opposition to the patient, who wants access to that medication.

There is absolutely no way for this not to become gaslighting, and no way for it not to become yet another stage on which our cultural biases play their well-worn roles. It’s a known fact that African Americans are considered less sensitive to pain, while women and Jewish people are considered weak and prone to complaining. (Somehow, despite the opposite stereotypes, all of these groups are similarly denied pain care.) These stereotypes appear in current medical textbooks. [4]

This page is from a 2014 nursing textbook titled Nursing: A Concept-Based Approach to Learning. After this photo went viral on social media in 2017, the publisher, Pearson, apologized and released an updated edition of the textbook with this section removed.

The other problem with “not all pain is intolerable” is that, while pain usually has physiological causes, its perception is subjective. Feelings of pain are processed in the brain, so all pain, by definition, is “all in your head.” That fact is often used to gaslight people, but if anything it should be the other way around. That pain is subjective means there’s no way to know if someone else’s pain is “that bad.” Every method that’s been created to try to objectively rate someone else’s pain is a dismal failure, because you simply can’t.

Opiates have high risks, especially when mismanaged. But lots of important medical treatments have high risks. Besides its serious short-term side effects, chemo has a high likelihood of causing at least a few of the following permanent effects: neuropathy of the hands and feet, cognitive impairment, bone and joint pain, elevated risk for various cancers, heart disease/failure, lung damage, infertility, hearing loss, and osteoporosis.

“But wait!” you may say. “Cancer kills, but chronic pain doesn’t!” You got me there. Except not really, because first of all, not everyone agrees that a lifetime of excruciating pain is better than death. For instance, I don’t. Second, severe and untreated chronic pain absolutely does kill. It can increase the risk of suicide and actual opiate abuse and overdose, as well as alcoholism and complications thereof. People who become sedentary due to pain have a higher risk of dying of heart disease, diabetes, and literally any other disease for which being sedentary puts you at risk. People with untreated pain may be unable to work, and their ambiguous medical status can make them ineligible for Social Security. Poverty is itself a risk factor for just about everything.

Which brings me back to my opening analogy. Who decided that the risks of living with severe pain are preferable to the risks of taking opiates? Why do they get to make that decision for patients? What the fuck happened to informed consent?

Opiate addiction is obviously a very serious health issue, but it’s not untreatable. Most people with addiction recover. Many of these other potential risks I described, both of chemo and of untreated chronic pain, are permanent.

I have always supported access to effective pain medication, including before my surgery, but before then I would’ve said that I’d personally rather deal with pain than take opiates for longer than a day or two and risk addiction. But the combination of gaslighting and physical suffering I experienced changed my mind. I have been in every way diminished by that experience, and it didn’t even last that long compared to other people. [5]

No, I didn’t need that pain “pushed down to zero,” and that quote is an unfair strawman. I needed that pain managed. I needed to not want to kill myself so I could focus on recovery. Ibuprofen didn’t do that. Tylenol didn’t do that. Muscle relaxers didn’t do that. Percocet didn’t even do it, because the hospital staff had allowed my pain to spiral out of control while they hemmed and hawed and condescended and argued with me about it.

At that point I was on my own. That I had resources of strength that enabled me to survive that without resorting to illegal drug use or having a complete mental breakdown diminishes neither the severity nor the ultimate Sisyphean pointlessness of what I went through.

Incidentally, I’m not even the type of patient that this conversation was supposed to be about. I’m not a chronic pain patient. I had a serious and complicated surgery, but one that has a predictable and relatively short-term recovery process. When experts talk about the risks of opioid prescriptions, this isn’t the situation they’re usually talking about. Yet, as my social worker later suggested, I had gotten caught in the web of Ohio’s new “opioid guidelines.” The pendulum has swung in the other direction, and it knocked me on my ass on its way there.

So, I fully admit that I can’t be impartial about this issue. But because I can’t be impartial about it, I’m well-positioned to report on its devastating outcomes. I dissociate when I have to return to that hospital. I break down bawling in doctors’ offices when they ask me about my experience. I’ve lost almost all trust in the medical system that put my cancer into remission and saved my life, because in so doing it gaslit and traumatized me in a way that, unlike the cancer itself, was one hundred percent avoidable.

And I am so, so lucky compared to others. My pain was temporary.

I see a lot of pundits talking about how to reduce opioid prescriptions and “get people off” opioids. These are the wrong questions to be asking. Here are some better ones:

  • Is pain a valid medical issue, or is it not?
  • Who is the best authority on a patient’s pain severity—their doctor, a state government, or that patient?
  • What are the long-term risks and costs of unmanaged chronic pain?
    Which of the “alternative approaches” to pain management being suggested to patients are based on scientific evidence?
  • On average, medical school students receive 11 total hours of training on pain out of thousands of total hours of education. Are we going to do anything about that?
  • In a culture with sayings like “No pain, no gain” and “What doesn’t kill you makes you stronger,” are we prepared to acknowledge that pain carries no intrinsic moral benefit and that people who want to reduce their suffering should be able to do so?
  • “Informed consent” means that patients are informed of potential risks, benefits, and alternatives for each treatment, and then allowed to decide for themselves which treatment to choose. Does this apply to chronic pain?
  • The majority of substance abuse treatment in this country still utilizes outdated, unscientific methods that rely on religion and moralizing rather than sound evidence. Are we going to do anything about that or nah?
  • Every single client I’ve ever worked with who was or had been addicted to opiates had one or both of the following untreated issues in their history: 1) repeated psychological trauma, usually sexual assault/abuse, or 2) years of disabling physical pain. What are we doing about that? Specifically, how fucking dare any member of Congress vote for any opioid-related legislation while confirming a man accused of rape by multiple credible witnesses to the Supreme Court?

Honestly, until I see some real answers to these questions, I don’t really care about reducing opioid prescriptions or forcing anybody off of them.


[1] https://thehill.com/policy/healthcare/380559-anti-abortion-lawmakers-lay-groundwork-for-roe-challenge

[2] https://www.vox.com/science-and-health/2018/9/25/17327976/opioid-epidemic-painkiller-prescriptions

[3] https://www.vox.com/policy-and-politics/2018/9/28/17915696/voxcare-opioid-epidemic-package

[4] https://www.insidehighered.com/news/2017/10/23/nursing-textbook-pulled-over-stereotypes

[5] The full story of my surgery and its aftermath is something I’ve addressed elsewhere on social media, and will be discussed in the book I’m working on. But the nutshell version is: I had a double mastectomy with reconstruction and was afterwards denied almost all but the weakest prescription pain medication, and gaslit and condescended to when I asked to be given proper pain management.


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Who Decides When Pain is “Intolerable”?

Intuitive Eating Made Me Miss My Flight

(But, in the words of the great Rebecca Bunch, the situation’s a lot more nuanced than that.)

Rebecca Bunch from Crazy Ex-Girlfriend

Last night I was supposed to be on a flight to DC. I arrived at the airport straight from work with some time to spare, checked my luggage, went through security, bought a snack, and arrived at the gate to find that the flight had been delayed by two hours. It was 7 PM. My usual dinner time. I ate some of my almonds but found my hunger worsening. With the delay I would not arrive in DC until about 11 PM, plus a half-hour ride from the airport, so it would be nearly midnight by the time I could finally have a hot, nutritionally complete meal—my first since lunch at noon. What to do?

Lately I’ve been working with a dietician[1] on intuitive eating, a radical (but not new) approach to food in which you learn to pay attention to your body’s hunger cues and eat things that feel good to you. No numbers are involved in this process at any point. It’s not a weight-loss program, or even a “health” program, really. It’s more of a “rebuild a healthy relationship with food and be more mindful” program.

Most people, even those who have a relatively healthy body image and few issues around food, have taught themselves to ignore bodily cues like hunger, satiety, and energy. That’s because bodies are inconvenient and our society demands that we run on its schedule, not on our bodies’ schedules. If lunch is at noon then you eat at noon. If you have a lot of work to do and don’t have time for eating, you keep working until you can stop. If we’re eating now then you eat now even if you’re not hungry. If dinner is meatloaf and broccoli then you clean your plate before you can leave the table because of [insert racist and classist cliche here]. If salads leave you feeling weak and tired but salads are clean and healthy and you need to eat clean and healthy, then you eat salads and feel weak and tired and tell yourself it’s because of something else. If the flight is at 7 PM and there’s no time for dinner beforehand, then you grab a snack and head to the gate, and if the flight is delayed and there’s no one with you to text you updates, then you stay at the gate in case the flight leaves suddenly and you worry about your worsening hunger later.

Recently finished chemo? Recently had a double mastectomy? Recently started hormone suppression meds that put you into early menopause, causing hot flashes, fatigue, weakness, and confusion, especially if you don’t eat properly? Don’t worry about it! Wait at the gate.

Needless to say, I didn’t do that. I went to a pizza place not far from the gate, ordered myself a small pizza with olive oil, bacon, onions, and mushrooms, listened for any flight announcements, did not hear any flight announcements, refreshed the flight info on Google, and missed the flight anyway.

“Should’ve stayed at the gate,” the gate agent said when I appeared half an hour before the flight’s rescheduled departure and inquired what the fuck.

But I was exactly where I needed to be—taking care of my body so that it takes care of ME on my trip.

Now it’s the morning after, and I’m on my rebooked flight to DC, somewhat frazzled but nevertheless feeling energized enough to enjoy my weekend. Because last night when I started to feel really hungry, I had a complete meal with carbs, fat, protein, and fiber, along with hot tea and later water.

Bodies are inconvenient. I’ve tried the thing where you replace your meals with “healthy snacks” because you can’t make time to eat meals. It doesn’t work. I’ve tried the thing where you grab greasy fast food and bring it on the plane with you because you don’t have time for anything else. It doesn’t work. I’ve tried ignoring the problem. It doesn’t work.

What works is paying attention to my body’s physical sensations and responding to them with a combination of carbs, fat, protein, fiber, water, rest, physical activity, and sleep.

In fact, that’s probably the only thing that ever would’ve worked. But until I got so sick that I HAD to stop and pay attention to it, I ignored it like almost everyone else does.

(No, ignoring my hunger did not cause my cancer, but having cancer caused me to stop ignoring my hunger.)

When you start noticing your body’s cues and responding to them appropriately, you may also start missing flights. Or turning down opportunities, or no longer eating some foods you thought you liked but turned out to actually make you feel bad, or being late to things because you realized you needed to eat first but you weren’t hungry early enough to eat early enough to not be late. You may decide that you can’t be vegan after all, or that you don’t need to eat meat after all. You may notice that you don’t get hungry at 7 AM, 12 PM, and 6 PM. You may get hungry at totally different times. You may need to adjust your work schedule to accommodate this.

You may find a way to avoid many of these potential problems by being strategic about bringing snacks with you or taking breaks from things. But sometimes you’ll forget, or it won’t be enough.

You may also find yourself feeling better, physically and mentally. You may stop sending yourself on guilt-trips over food. You may realize that stopping at Dairy Queen for an ice cream cone after work is actually a great way to boost your mood and make sure you don’t get hungry until you’ve had time to make dinner.

You may even find yourself noticing other types of bodily cues more, too—for instance, that the party is loud and you need a break from the noise, and if you take a break now, you won’t be overwhelmed and will be able to return and stay for the rest of the party and enjoy yourself. Or that these shoes are so uncomfortable that it actually impacts your mood and productivity, so wearing them just isn’t worth it anymore. Or that you always feel vaguely uncomfortable and on edge around this particular person and maybe it’s time to try to figure out why.

Yeah, it’s inconvenient. It makes me feel over-sensitive, fragile, high-maintenance, and a lot of other things we often label women with. It’s difficult that at a moment when I most need to get past my preoccupation with my body’s weakness and vulnerability, the self-care I need the most seems to just highlight those things more and more.

But every time I make the decision to honor my body’s cues rather than ignore them, I can feel that I’ve taken another small step towards well-being. Towards working as a team with my body rather than fighting it every step of the way. Towards feeling at home in myself again.

A missed flight starts to seem like a small price to pay.


[1] If you live in Ohio, you may be able to work with my dietician! Find her here: https://www.kristenmurrayrd.com/

More info about intuitive eating here: http://www.intuitiveeating.org/


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Intuitive Eating Made Me Miss My Flight