Claire Sandoval

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Gender Affirming Healthcare - Understanding WPATH Letters

August 2024, Claire Sandoval, Undergraduate Intern 

What is a WPATH Letter?

When considering essential gender affirming healthcare it is impossible to ignore the role of the WPATH letter.  WPATH letters, or letters of support, are written by mental health professionals who specialize in gender-affirming services  so that a client can receive gender affirming healthcare including top surgeries, bottom surgeries, and hormone replacement treatments for adolescents, among other things. Both surgeons and insurance companies will usually require a WPATH letter to understand the client’s situation. These letters of support inform the specific type of surgery a client needs and deems the procedure medically necessary. The World Professional Association for Transgender Health (WPATH) sets guidelines to ensure people are receiving the correct care and are appropriately prepared for these services. 

Criteria for Gender Affirming Surgery 

A mental health professional will see a client before writing a letter of support to discuss important aspects of their history, as well as their aftercare plans. Requirements for gender affirming surgeries may vary based on insurance companies, providers, and regions. These letters will typically consider a client’s gender history and ability to fully understand the procedure, give informed consent, make independent decisions, and receive proper surgical aftercare.  A diagnosis for Gender Dysphoria is also necessary in the state of Colorado. 

Some factors that may prevent a person from receiving a letter of support are the inability to provide informed consent, some types of substance abuse, or not having a safe place to perform aftercare tasks and recover from a surgery. The counselor and client will discuss these obstacles in order to help the client get access to the resources they need to receive the medically necessary and life saving care they are seeking. 

Considerations and Challenges

Some criticism of WPATH letters include the concern that the letters become a daunting hurdle for clients who need gender affirming healthcare, especially those who lack accessibility to physical and mental healthcare in general and those who may be in unsafe situations due to no fault of their own. Another challenge clients face is that they cannot receive gender affirming surgery if they do not have the appropriate care lined up after the surgery such as transportation support to and from the hospital. It can be argued that requiring a WPATH letter acts as a gate that blocks life saving care for clients in a way that is disproportionately more difficult than a cisgender person receiving gender affirming treatment.

Another criticism lies within the necessity for a Gender Dysphoria diagnosis. The DSM currently lists criteria for Gender Dysphoria as strong incongruence with one's sex characteristics and expressed gender, conviction that one feels emotions and reactions of another gender, and desire to be treated as another gender, among other things.  The DSM does not accurately represent gender dysphoria, and rather pathologizes the experience of being gender expansive. Since gender dysphoria is experienced differently for each person, these criteria may be limiting for gender expansive people to receive life saving care, especially for those who may not fall into a binary description of gender. 

Takeaways 

WPATH letters exist in the intersection of healthcare, systematic oppression, identity affirmation, and social justice. Ongoing education and advocacy are essential to ensure they continue to evolve in ways that show the individuals seeking care dignity, respect, and accessibility. Understanding the role of WPATH letters remains important to affirming the identities and rights of gender-diverse communities. If you are seeking gender affirming care, please feel welcome to make an appointment on the Contact Me page to discuss how this care might look for you! If you are looking for more information about what informs the WPATH assessment process and want to read more about the WPATH Standards of Care, please visit: https://www.wpath.org/

The Window of Tolerance and Emotional Regulation

September 2024, Claire Sandoval, Undergraduate Intern

What is the Window of Tolerance

As we move through life we experience a range of emotions that can include stress, anxiety, anger, and other emotions that can sometimes lead to overwhelming feelings or a shut-down response. The term “window of tolerance” introduced by Dr. Dan Siegel, refers to the optimal level of arousal that allows a person to navigate daily life. It is recognized as having the ability to think clearly along with feelings of calmness, openness, presence in the moment, and a readiness to take on challenges. Essentially, when we are in our window of tolerance, we are in a state of emotional regulation that allows us to respond instead of react,  and to cope with stressors in an effective way. 

States Outside of the Window of Tolerance

When we are outside of this optimal zone of arousal- the window of tolerance- we can move into states of hyperarousal or hypoarousal. 

Hyperarousal occurs when the body’s nervous system is activated, even if it is not necessary. This state can be characterized by irritability, panic, high energy, or overwhelm. Because of this physical response in the nervous system, we might react impulsively or become easily overwhelmed by stressors. Hyperarousal can be triggered by a perceived threat, specific emotions, or traumatic memories, brought on as the result of an overactive parasympathetic nervous system.

Hypoarousal, on the other hand, is recognized as the shutdown response. It can be characterized by feelings of apathy, disconnect, dissociation, depression, or or numbness. It can also be triggered by a perceived threat, specific emotions, or traumatic memories, brought on as the result of an overactive parasympathetic nervous system. 

Managing the Window of Tolerance

Understanding the window of tolerance can provide insight into why this happens and how we can manage our emotional experiences in states of hypoarousal or hyperarousal. It can also help clarify triggers and emotional responses to them. It is important to remember that these are physical reactions in your body, and that awareness allows for the appropriate next steps to be taken. Approaches to practice coming back to the window of tolerance will depend on the person and situation, but here are some skills that may be helpful to add to your personal toolbox. 

Some strategies to return to the window of tolerance for hyperarousal:

- Meditation or diaphragmatic breathing

- 5 senses grounding 

- Splashing cold water on neck and wrists

- Positive containment imagery 

And for hypoarousal:

- Physical movement and engaged posture

- Tossing a ball back and forth

- Breathing exercises

- Sacred space/safe place imagery

Learning Objectives

A therapist or counselor can guide you in practicing these strategies and supporting you if they are not working for you. When you are informed, you are more likely to recognize and have the ability to take steps towards regulating yourself when experiencing overwhelming emotions at any time. Ultimately your body is taking the steps it feels necessary to protect you, so give yourself compassion and space to return to the optimal window of arousal. The goal is to navigate effectively and gain an understanding of your emotional states, not to erase all overwhelming emotions. Ideally, understanding the window of tolerance allows us to lead a more balanced life, as well as feel prepared to take on what the day may bring!

The Body Neutrality Movement

October 2024, Claire Sandoval, Undergraduate Intern

What is Body Neutrality

In a social landscape that often prioritizes appearance over well-being, the concept of body neutrality is a perspective that encourages one to focus on how our bodies function rather than how they look. It’s a philosophy that promotes acceptance and appreciation of our bodies without the pressure to love every inch of them, or consider them with a false positivity. In recent years, the concept of body neutrality has been gaining traction and visibility in the media, with outlets such as The Washington Post, Time Magazine, and The New York Times discussing the approach. 

Body Neutrality vs. Body Positivity

Body neutrality is the concept that our bodies are not just reduced to weight and appearance,  but instead  tools that enable us to experience life. This idea, presented by Anne Poirer in her book The Body Joyful, suggests that instead of striving for constant body positivity, you can adopt a more approachable and achievable mindset through body neutrality. While body positivity encourages people to love every part of their body no matter shape or size, body neutrality encourages us to shift our focus from appearance-based thoughts to simply observing the body without judgment. Body neutrality encourages the acceptance that every body simply exists as it is.

This means appreciating our bodies for their nonphysical characteristics over how they look. It’s about recognizing that your worth is not tied to your appearance. It’s about accepting that bodies will change throughout our lives, whether through aging, weight gain, pregnancy, or other life events. This doesn’t mean ignoring or denying feelings we have about our bodies, just reframing thoughts and fostering a mindset where you can understand all the great things your body does as a vessel to move throughout life. For many, body positivity may seem like an unattainable goal, and if you don’t love every inch of your body all the time you may feel discouraged. Some may argue that the body positivity movement also places a lot of emphasis on appearance, and can lead to feelings of dissatisfaction with your body. 

Focusing on body functionality instead of appearance can also be explored through concepts such as health at every size, which advocates for fair healthcare for people of all sizes without bias or discrimination. It recognizes that there are more ways to be healthy than society’s narrow definitions, particularly those that are often emphasized in the media. Incorporating this philosophy into your thinking can lead to a greater acceptance of self and find a place to settle within body neutrality. 

How to Practice Body Neutrality

Some ways to practice this alternate way of thinking are 

• Focusing on what your body can and does do for you: Your body is a vessel that brings you through life and allows you to do the things you love! If you did not have your body, you would not be able to enjoy time with friends or experience your favorite song.

• Shut down unwanted conversations: There are inevitably going to be body-oriented conversations around you, but luckily there are ways to shut this down. Saying things like “This is not a conversation I want to have” or “I’m not the right audience for this” are quick ways to close these nonessential or detrimental conversations and comments. 

• Being patient with yourself: We have been socialized to put a lot of importance and emphasis on how we look, and unlearning these habits will take conscious effort and practice over time. Giving yourself the compassion and acceptance to recognize unwanted thoughts and then reframing them will take practice!

Takeaways

Body neutrality offers a liberating alternative to expectations of body positivity that some may find unrealistic or dishonest to themselves. By shifting the focus from how our bodies look to what they can do, we can cultivate a healthier, more compassionate relationship with ourselves. Embracing this philosophy may take time and practice, but the journey toward body neutrality can lead to a more fulfilling life. 

Understanding Cognitive Processing Therapy (CPT): Managing Trauma Responses

November 2024, Claire Sandoval, Undergraduate Intern 

Cognitive Processing Therapy

Cognitive Processing Therapy (CPT) is an effective, evidence-based treatment designed to help individuals reduce symptoms of PTSD that have developed after experiencing a variety of traumatic events. CPT combines cognitive-behavioral therapy techniques with a focus on understanding and reshaping the way trauma survivors think about their experiences. The ultimate goal of CPT is to help individuals modify and challenge the negative thoughts and emotions associated with trauma, leading to improved emotional well-being and improved ability to navigate stressors and challenges in life.

CPT is based on how we make meaning from a traumatic event, and how trauma can significantly alter how we perceive ourselves, others, and the world around us. This thought process can prevent healing, keeping individuals stuck in patterns of fear, anger, or shame. Through CPT, people learn how to identify and challenge these thoughts, and replace them with more balanced ways of thinking.

The therapy typically involves 12 weekly sessions, about 3 months, where individuals work with a professional to understand the impact of trauma on their thoughts and beliefs through psychoeducation and cognitive therapy techniques.

The Role of Stuck Points in CPT

A critical element in CPT is the identification of stuck points—the negative beliefs that trap individuals in their trauma.  These thoughts keep someone from moving forward in their healing journey and often reflect unrealistic, overgeneralized, or distorted thinking patterns, such as:

• “It was my fault.”

• “I can't trust anyone.”

• “I can’t protect myself.”

These stuck points are often rooted in the trauma experience, where the individual feels powerless, guilty, or unsafe. They may be tied to feelings of shame, anger, or helplessness, which can keep the person locked in the past.

During CPT, individuals learn to recognize these stuck points and examine them critically. Through this process, patients are guided to challenge their beliefs and test whether they are truly accurate or helpful. For example, a stuck point like “I am to blame for what happened” can be re-evaluated through a more compassionate and realistic lens, like “I couldn’t control what happened, and it’s not my fault.”

Overcoming Stuck Points

One of the most empowering aspects of CPT is that it introduces the tools to challenge and rewrite these stuck points. With practice, individuals begin to see the world and themselves in a more accurate and realistic way, and they are able to utilize the skills they learned to create a more fulfilling life.

By addressing these deeply ingrained negative thoughts, CPT fosters a sense of personal agency, allowing people to reclaim their lives. Instead of finding themselves stuck in maladaptive thought patterns, they are able to positively adjust their thought process and gain insight into the ways their experiences have affected them. 

In summary, Cognitive Processing Therapy is an invaluable tool for those recovering from trauma. By identifying and addressing stuck points, CPT helps individuals reshape their thought patterns, reduce the intensity of PTSD symptoms, and move forward in their healing journey with greater hope and resilience with new skills to navigate their lives.

Trauma Informed Therapy

January 2025, Claire Sandoval, Undergraduate Intern

Trauma-informed therapy is an approach to mental health care that acknowledges the profound impact trauma can have on an individual’s life. Trauma responses can manifest through emotional distress, difficulty in relationships, or even in seemingly ordinary tasks that become overwhelming. In response to these effects, trauma-informed therapy has become an essential approach, emphasizing safety, trust, and empowerment for individuals who have experienced trauma. By recognizing this impact, trauma-informed care aims to create a safe, supportive environment where clients feel understood, empowered, and equipped to reroute maladaptive behaviors.

Adaptive Tendencies and Maladaptive Responses

Adaptive tendencies are survival mechanisms that have evolved to protect us from danger and help us navigate challenging situations. For instance, heightened awareness of potential threats, avoidance of risky situations, or heightened vigilance are all adaptive responses that keep us safe and alive. However, when these mechanisms are overactivated or become ingrained in our behavior, they can turn maladaptive. For example, someone who has experienced trauma may develop a constant sense of hypervigilance, where they are perpetually on alert, even in safe environments. Similarly, avoidance behaviors, which originally help protect from distressing memories or situations, can turn maladaptive if they prevent an individual from engaging in normal life activities or processing their trauma. These once helpful responses can contribute to anxiety, isolation, and other mental health struggles, interfering with an individual’s ability to function in day-to-day life. In this way, adaptive mechanisms designed to keep us safe can become maladaptive when they persist beyond the context in which they are needed.

Core Elements of Trauma-Informed Therapy

At its core, trauma-informed therapy is built on the understanding of three key elements: realizing the prevalence of trauma, recognizing how trauma affects individuals, and responding by putting this knowledge into practice. A trauma-informed care provider seeks to ensure that treatment is sensitive to these experiences, emphasizing safety, trust, and empowerment through building the therapeutic relationship.  It involves adapting the therapeutic process to avoid re-traumatization, helping clients navigate their healing without feeling overwhelmed or triggered.

Additionally, trauma-informed therapy is not just about understanding trauma; it’s about creating a compassionate, supportive environment where healing can take place. This is reflected in a counselor's actions and words in session, alongside the finer details such as the language used in paperwork and the counselor’s overall presentation. Every aspect of the therapeutic process, from the way the counselor interacts to the tone they use, is designed to create a safe, welcoming space where clients feel valued and empowered in their healing journey.

The ARC Framework

One of the models used in trauma-informed therapy is the ARC Framework, which stands for Attachment, Regulation, and Competency. These are critical areas that are routinely shown to be negatively affected by traumatic stress and attachment disruptions, and when addressed, they can predict resilient outcomes.

• Attachment: Trauma can interfere with a person’s ability to form secure, trusting relationships. The ARC framework helps individuals develop healthier attachments by fostering safe, supportive, and predictable relationships, whether with care providers, family members, or peers.

• Regulation: Many trauma survivors struggle with emotional and bodily regulation. The ARC model emphasizes the importance of helping individuals learn to regulate their emotions, behaviors, and physiological responses (e.g., managing fight-or-flight reactions). This often includes grounding techniques, mindfulness practices, and other tools to help clients regain a sense of control over their emotions.

• Competency: Trauma can erode a person’s sense of competence, leaving them feeling incapable or powerless. The ARC framework works to restore confidence by helping clients build and develop skills for problem-solving and self-control. This aspect encourages clients to regain a sense of agency and self-efficacy.

By focusing on these three areas trauma-informed therapy, with the support of the ARC framework, can be a powerful way for individuals to heal from the effects of trauma, rebuild their resilience, and regain a sense of control and purpose in their lives.

Extending Trauma-Informed Care Beyond Therapy

Adopting a trauma-informed perspective extends beyond the therapy session and involves actively engaging with and supporting the community as well. Demonstrating positive action and being an example of empathy and understanding outside of the therapy room is essential to truly connecting with and helping those affected by trauma. It means being an advocate for healing and showing a commitment to creating an environment of safety, respect, and care in all aspects of life. Whether through the ARC framework, in-session support, or out in the community, this trauma-informed lens offers a pathway to recovery that honors the complexity of trauma and the strength of the human spirit.

Understanding Harm Reduction- A Human Rights Centered Approach

February 2025, Claire Sandoval, Undergraduate Intern

What Is Harm Reduction

Harm reduction is a public health strategy that aims to minimize the negative consequences of drug use without necessarily eliminating the behavior itself. It focuses on reducing harm to individuals and communities, promoting safety and education, and improving overall well-being. This is not about encouraging risky behaviors, but rather about recognizing that some behaviors like substance use are part of people's lives, and outright prohibition or abstinence might not be realistic or effective for everyone. Instead, harm reduction focuses on practical measures that reduce risks and prioritize safety, meeting people where they are in their journey, and accepting that every individual is deserving of respect and care. 

Core Principles of Harm Reduction

The National Harm Reduction Coalition recognizes 8 foundational principles to harm reduction. These are: 

1. Accepting that drug use is a part of our world and chooses to work towards minimizing the harmful effects rather than ignoring or condemning them

2. Understanding that drug use is a complex phenomenon, and acknowledges that some ways of drug use are safer than others

3. Establishes quality of life and well-being as the criteria for successful interventions and policies

4. Calls for non judgemental and non-coercive services and resources for people who use drugs and the communities where they live

5. Ensures that people who use drugs and have a history with drug use have a voice and part in creating programs and policies intended to serve them

6. Empowers people who use drugs to see themselves as the primary force in reducing harm in their lives and encourages people to engage in community connection, sharing information, and offering support for each other in strategies which meet their actual conditions of use

7. Recognizes that people’s social inequalities and positions affect people’s capacity and vulnerability for effectively dealing with drug-related harm

8. Does not attempt to minimize or ignore the real and tragic harm and danger that can be associated with illicit drug use

Why Harm Reduction Works

Rather than a “one-size-fits-all” approach, harm reduction acknowledges that people are at different points in their lives, and their behaviors are shaped by a range of personal, social, and economic factors. It offers an alternative to traditional approaches that focus solely on ending or preventing drug use by recognizing that many individuals may not be ready or able to quit immediately but still deserve access to care. Harm reduction provides evidence-based prevention and reduction strategies that prioritize safety and well-being, meeting people where they’re at and supporting them in making safer choices. Some examples of harm reduction policies in action include needle exchange programs, supervised injection sites, and the distribution of naloxone to reverse opioid overdoses. These strategies are proven to reduce harm, prevent disease transmission, and save lives, while also providing individuals with pathways to care and support.

A Compassionate Step Forward

Harm reduction is a pragmatic, compassionate, and evidence-based approach to public health. It offers a non-judgmental space for individuals to engage in safer practices while also supporting their broader health and well-being. By focusing on minimizing harm rather than expecting complete abstinence, harm reduction acknowledges that wellness is a complex, ongoing process shaped by various factors.

As we continue to address issues like substance use it’s crucial to understand and embrace harm reduction. It’s not only about reducing harm—it’s about creating a society that treats people with dignity and offers the support they need to lead more fulfilling lives.