Pride Month: Where Are You and Where Are You Headed?

As the month of June fills with celebrations of Pride and authenticity, we celebrate the remarkable progress that has been made over the past decades. That progress is visible not only during Pride Month but throughout the year.

On television, in movies, and across social media, we see beautiful same-sex couples, families raising children, people openly celebrating their identities, and individuals speaking candidly about their sexuality and relationships.

With the advent of PrEP and PEP, many gay and bisexual men, in particular, have experienced a degree of sexual freedom that would have been almost unimaginable during the height of the AIDS epidemic.

It is a world of freedoms that generations before us fought to achieve. But are we all living in that world?

For every person who is able to live openly, there are countless others whose reality remains very different.

Many have not come out to those they love most, fearing that revealing such a fundamental part of themselves could irreparably damage those relationships.

Others have come out but continue to live with conditional acceptance rather than genuine affirmation. They are tolerated but never fully embraced. Their partners are never quite considered family. Important conversations remain forever unspoken. Family gatherings become exercises in careful self-editing. At work, they remain silent in environments that are openly hostile or that subtly communicate that authenticity still comes at a price.

Perhaps some have not yet come out even to themselves. The process of hiding can become so opaque that the person no longer experiences it as hiding. Others defend themselves differently, directing toward openly LGBTQ+ people the very hostility they cannot tolerate within themselves.

Yet even for many who appear to be living openly, the past often remains an open wound.

As a psychiatrist, I see how frequently LGBTQ+ patients initially describe their childhood as devoid of any trauma or adversity. They describe supportive childhoods and loving families and classmates. Yet as psychotherapy unfolds, another side of their story gradually emerges. Parents who never truly accepted them. Years spent hiding relationships. Partners who were never invited into family life. Conversations that never happened. The constant effort not to disappoint the people whose love mattered most. A lingering hope that one day they might finally receive unconditional acceptance.

It is true that many of these experiences may not resemble what we traditionally call trauma. There may have been no violence, no dramatic confrontation, no single event that forever divided life into a "before" and an "after." But how can one regard these years of concealment, invalidation, conditional acceptance, and chronic vigilance as "a happy childhood"?

Like many forms of chronic adversity experienced by minority groups, these experiences are often accepted as simply "the way things are." Many LGBTQ+ individuals grow up believing that love will always come with conditions, that certain conversations are better left unsaid, that some relationships will never be fully recognized, that hiding parts of oneself is simply the price of belonging. Hypervigilance becomes second nature. Self-censorship becomes ordinary. One adapts so thoroughly that the adaptation itself becomes invisible.

That normalization may be, in part, precisely what makes these wounds so difficult to recognize, both for those who carry them and for the clinicians who care for them.

What are the consequences of this injury?

The consequences extend far beyond psychiatric diagnoses such as depression, anxiety, or suicidality. While these outcomes are well documented in the scientific literature, they represent only part of the picture.

When a part of ourselves becomes the target of hate and appears incompatible with love, the consequences may be devastating and enduring. The effects extend into several aspects of one's identity and self-regard, our pattern of thinking about others and the world, how we experience our emotional lives, and how we relate with others.

One wonders, "Who might I have become had I been free to be myself from the beginning?" How many invisible losses hide behind that question? First relationships that could not be lived openly. Adolescence spent hiding instead of exploring. Family milestones experienced with secrecy rather than celebration. Years devoted to survival and hypervigilance rather than curiosity, spontaneity, and growth…

Where does hate go?

To live as the target of hate is not merely a matter of losses. Perhaps one of the most perverse consequences of these experiences is internalized homophobia or transphobia. The voices that once judged, rejected, or shamed eventually become our own.

We hate ourselves and we may also hate others.

In fact, belonging to a minority does not make anyone immune to prejudice against that very minority. Some of the harshest hate directed toward LGBTQ+ individuals may come from members of the LGBTQ+ community themselves as they have inherited and internalized the same messages that once wounded them.

"Birds born in a cage think flying is an illness."

— Attributed to Alejandro Jodorowsky

Where are you headed?

Wherever you are in your process of self-discovery and acceptance of your identity and sexual orientation, I hope you are walking toward a place where you are free to become—and to love—your authentic self.

If, along the way, you find yourself struggling emotionally or mentally, please don't hesitate to reach out for help.

Helder Araujo MD PhD

Work is only one domain of life, but is it really all that different from the others?

About how work may reactivate older patterns of relating, why professional environments can feel both emotionally intense and deeply fragile, and how burnout, repetition, and self-awareness become intertwined in the way we navigate professional life.

We often divide our lives into compartments — the professional, the personal, the social, the intimate. We develop different expectations for each of these domains. At times, we may even feel as though we are different people within them, behaving as different versions of ourselves depending on the context.

We come to believe this separation is evidence of maturity, adaptation, or professionalism. At work, for example, we are expected to behave in specific ways, and we are valued and evaluated according to those expectations.

While these separations do exist, there is inevitably some continuity across them — within ourselves, within others, and within the situations we encounter.

Have I been here before?

We speak of demanding bosses, intrusive coworkers, micromanagement, or the pain of being overlooked as though these experiences existed in isolation. Yet often there are invisible threads connecting these encounters to earlier experiences in our lives.

Workplaces may expose us to completely new people and experiences, but to some extent, many (not all) situations — and many people — are repetitions. A new boss may share striking similarities with important figures from our past. Certain workplaces may unconsciously revive older relational dynamics.

When we overlook these continuities, we may suffer intensely while believing that some wounded part of ourselves — and some “enemies” — exist only at work.

If we pause long enough, we may notice something about the magnitude of our own responses. We may become surprised by how deeply affected we are by a supervisor, an institution, or a workplace conflict. And we may wonder whether that present situation carries layers from our past.

When we pursue that line of thought, we may reach a point where we are able to give each component its proper weight: what started in the present, what comes from the past.

What is more, we may be able to remove some of the layers that are not necessarily called for in the current situation — both in ourselves and in others.

My boss at work may resemble the overcritical or neglectful parent whom I was never able to please, whose attention I could only obtain when I was perfect. But they are not the same person.

Why reenactments at work feel so intense — and so fragile

In many families, relationships are sustained by an assumption of permanence. People may show their best and worst selves while the relationship itself remains relatively durable. Of course, there are important exceptions, and many family relationships do fracture, but intimate relationships often contain some possibility of repair.

Parents do not literally fire children, nor children their parents. Spouses do not usually divorce after the first argument. If conflict emerges, there may still be room to restore the relationship.

Some work environments may resemble families more than many actual families do. Dysfunctional workplaces may, for example, have bosses who behave like “authoritarian parents” and who are satisfied only with highly submissive children. Under that kind of leadership, employees may not only feel that they are being treated like children, but they may also use older ways of coping under difficulty. Compliance, rebellion, helplessness, perfectionism, hypervigilance, withdrawal — all may reappear with surprising force.

Still, at work we cannot react the same way we might react within our families. Employment is inherently conditional. It depends on contracts, evaluations, probationary periods, letters of recommendation, references, and the judgment of people who may have enormous control over our future. To react angrily at work, for example, may cost us our job even when we had all the reasons — past and present — to feel angry.

Being caught in workplace dynamics without always having a feasible way out rapidly becomes a source of suffering that affects all domains of our lives. In many cases, it may result in burnout, anxiety, depression, or the opening of older wounds, including PTSD.

Navigating work difficulties with self-awareness

To say that our workplace difficulties will help us develop awareness of who we were and where we come from seems too pale a silver lining when we are in the thick of our suffering. That awareness, however, can help us navigate the actual problems before us.

We are often advised to navigate work difficulties professionally, but we may forget that we should also navigate them with awareness of ourselves.

To step back, pause, and understand how much of the present relates to the past may help us tolerate certain situations with greater clarity and proportion.

Sometimes the people and situations hurting us are not the original injury, but repetitions of something older. And understanding that may allow us to recognize that not every action around us is specifically designed to wound us. Many people are acting from their own fears, ambitions, limitations, or needs. We are caught in their world as much as they are caught in ours.

Likewise, our reactions may not always reflect who those people truly are, but rather what they represent to us and the reactivation of older ways of reacting. We may react with perfectionism, withdrawal, compliance, overachievement, or anger — the only ways we once knew how to survive.

To realize that some of our feelings, perceptions, and reactions may come from the past does not mean that we will reach a place where nothing affects us anymore or where difficult people suddenly become easy to work with.

It may, however, allow some distance from the immediacy of our reactions. It may help us respond with greater discernment rather than simply reenacting older patterns of feeling, thinking, and reacting.

To realize that parts of our past contribute to these situations does not mean that we can erase or reshape our ways of feeling, thinking, and reacting overnight.

Instead, that understanding should be accompanied by some compassion toward ourselves. That understanding can guide us toward an honest assessment of who we are and what actually works for us: what kind of leadership, what kind of environment, what kind of structure allows us to function well.

To know ourselves does not mean that we will stop compromising or that we will reject every environment that does not fully meet our needs. But it may give us a clearer sense of what to look for, what to avoid, and what we can realistically sustain over time.

With that knowledge, we may be better able to decide — with some balance between integrity and realism — what is possible and what is not, when to stay and when to move on.

- Helder Araujo MD PhD 

What Is Trauma? Understanding PTSD, Complex PTSD, and the Long-Term Effects of Trauma

Trauma is a highly complex subject, both for patients and clinicians. While people often associate trauma with catastrophic events, trauma may also emerge from repeated experiences that may not even seem traumatic to many people.

The way trauma presents can vary considerably. For some individuals, trauma presents through obvious symptoms such as flashbacks, nightmares, or hypervigilance. For others, the effects are far more subtle, appearing through chronic anxiety, numbness, shame, difficulties in relationships, or persistent patterns that are not always immediately recognized as trauma.

Treatment can also take very different forms. For some individuals, treatment primarily involves reducing intrusive symptoms and suffering. For others, processing trauma becomes a way of understanding themselves — understanding how certain ways of feeling, reacting, relating to others, and experiencing the world may have been shaped by earlier experiences.

What Is Trauma?

There is not a single universal definition of trauma, but most people would agree that experiences such as natural disasters, sexual assault, severe accidents, physical violence, sudden loss, war, or combat exposure can be traumatic.

However, other forms of trauma may be more easily overlooked. Experiences such as neglect, chronic criticism or humiliation, interpersonal abuse, unstable or unsafe environments, and attachment disruptions can all be deeply traumatic for many individuals, even if others may not immediately recognize them as such.

The subjective nature of trauma is therefore very important. The psychological impact of the experience — including how the individual processes it — is often what defines trauma. Some people appear more resilient than others even when their experiences were similar.

Equally important is recognizing that direct exposure is not always necessary for trauma to occur. Indirect experiences, such as witnessing another person’s trauma or suffering, can themselves become traumatic.

What Is the Difference Between PTSD and Complex PTSD?

As a psychiatrist who works extensively with trauma, I can say without hesitation that trauma may present in extraordinarily complex ways.

In some individuals, particularly those exposed to repeated trauma over long periods of time, trauma affects far more than isolated intrusive symptoms such as flashbacks, nightmares, or intrusive memories. It can appear as though the entirety of the person’s inner world has been shaped by traumatic experiences.

Clinicians and researchers have long attempted to capture this broader and more pervasive reality through the concept of complex PTSD (C-PTSD).

Why Is Trauma Often Missed in Mental Health Treatment?

Trauma is frequently overlooked in psychiatric and psychological settings. There are several reasons for this.

In many cases, trauma may remain unspoken during appointments because of hesitations coming from both clinicians and patients.

Some clinicians may hesitate to explore trauma because they fear overwhelming reactions that cannot easily be managed within limited appointments. Others may feel uncertain about how to approach trauma safely or effectively.

Patients themselves may also hesitate to discuss trauma because of shame, fear, difficulty trusting others, or lack of awareness regarding the relevance of certain experiences.

In other cases, trauma may be acknowledged but not adequately connected to the origins of one’s symptoms. For example, symptoms may instead be attributed primarily to other conditions such as ADHD, depression, bipolar disorder, anxiety, obsessive-compulsive disorder, or psychosis.

Why Is It Important to Explore Trauma in Psychiatry or Psychotherapy?

For many individuals, this is not really a question. Trauma is so present at the forefront of their minds that it becomes difficult to ignore, and the reason they seek psychiatric treatment is specifically to address it.

Others may seek treatment for reasons that they do not initially recognize as related to trauma, such as depression, anxiety, irritability, substance use, or relationship and work instability. For these individuals, recognizing that some experiences in their life were traumatic can be the beginning of a deeper understanding of themselves.

Even individuals seeking treatment for a particular trauma may sometimes overlook earlier experiences that are also worth exploring.

How Is Trauma Properly Assessed in Psychiatry and Psychotherapy?

Effective trauma treatment begins with careful and comprehensive assessment.

Assessing trauma requires understanding the experiences that were perceived as traumatic with openness, curiosity, and an effort to understand how the individual experienced those events from their own internal reality rather than through our own expectations.

This requires being capable of holding the complexity of one’s internal reality and being willing to work through feelings and thoughts that may be complicated and at times conflicting.

The assessment also requires understanding how those experiences affected the individual psychologically, relationally, and biologically over time.

It is important that we look not only into the past, but also into the present — into the dynamics that emerge during our days, our relationships, our reactions, and even during our nights when we fall asleep.

The assessment often involves understanding different parts of ourselves and different “selves” existing in different states of mind. At times, the adult part of ourselves may consciously long to “let go” of the trauma, while our inner child may continue holding on to it.

What Are the Goals of Trauma Treatment?

Treatment of PTSD and other forms of trauma may take various forms, ranging from different forms of therapy to medication management.

The goals of treatment are individualized and dynamic. Oftentimes, it is important to establish which symptoms are most debilitating and provide some degree of relief, whether that pertains to intrusive symptoms, mood, anxiety, irritability, or even psychosis in broader trauma presentations.

With time, other goals may emerge. Oftentimes, the goals go beyond symptom reduction and extend toward understanding oneself and finding new ways of relating to oneself and the world around us.

Why Are Antidepressants, Mood Stabilizers, and Antipsychotics Used for PTSD or Complex PTSD?

Patients are sometimes confused when medications such as antidepressants, mood stabilizers, or antipsychotics are prescribed for PTSD or complex PTSD.

However, psychiatric medications are generally selected based on the symptoms and neurobiological systems involved — not simply based on the traditional name of the medication category.

In many cases, medications are selected because trauma may affect mood, sleep, anxiety, perception, and the way individuals respond to stress in highly complex ways.

Medication treatment is therefore often approached through a broader and more individualized understanding of psychological functioning, neurobiology, and symptom patterns.

Trauma Requires Patience, Safety, and Compassion

Working through trauma can be deeply demanding. Even subtle exploration of trauma may trigger feelings of vulnerability, helplessness, fear, grief, shame, overwhelm, or numbness, and may even temporarily increase intrusive symptoms. The process is not linear, and at times it may feel as though things are getting worse when they should be getting better.

Because of this, trauma work often requires patience, consistency, safety, and compassion — both from clinicians and from patients themselves.

In Summary

None of us is entirely immune to traumatic experiences. At the same time, trauma affects different individuals in profoundly different ways.

Providers should not place themselves as evaluators of whether someone’s experiences were “bad enough” or whether someone should simply “let go” of their trauma.

Instead, providers are asked to approach trauma with careful assessment — past and present — from the perspective of the patient’s inner reality.

Once trauma is adequately understood, meaningful treatment can occur, and patients may gradually move toward lives that are less organized around trauma.

- Helder Araujo MD PhD

Understanding Bipolar Disorder: Psychological and Biological Perspectives in Treatment

Bipolar disorder is a complex condition. It encompasses a wide array of mood changes that are collected under a single diagnostic umbrella. The heterogeneity of bipolar disorder often makes it difficult for providers, patients, and their families to feel fully contained by any single explanatory model or treatment approach.

Interpretations of bipolar disorder often fall somewhere between two broad perspectives. On one end lies a psychological model, in which depression and mania are understood as responses of an individual’s mind to internal and external events. On the other end lies a biological model, which regards these mood extremes primarily as the result of neurobiological imbalance.

Similar distinctions emerge in treatment approaches for bipolar disorder. Someone who works primarily within a psychological framework will tend to understand mood changes in relation to events and dynamics in a person’s psychological life. In contrast, someone who operates within a biomedical framework may focus primarily on neurotransmitters and neurobiological mechanisms that can be modulated in order to stabilize mood.

These perspectives do not only influence the relationship between providers and patients. They often appear within families and friends as well. Patients who feel more comfortable within a psychological framework may struggle with others who believe their difficulties should be addressed primarily through medication.

On the other hand, patients who feel more comfortable within a biomedical framework may struggle with providers who emphasize psychological work and may instead request medication adjustments in the hope of restoring their sense of normality.

There Is Nothing Intrinsically Wrong With Viewing Bipolar Disorder From One Perspective or the Other

In the past, there was considerable debate about whether excessive reliance on psychological explanations deprived patients of effective medical treatment for bipolar disorder. This concern is not unreasonable. At the same time, it is also possible to argue that providers who rely exclusively on biological explanations may deprive patients of a deeper psychological understanding of mood changes.

Fortunately, these perspectives do not have to be mutually exclusive. In many cases, combining psychological and biological approaches provides a more comprehensive understanding and a more effective form of bipolar disorder treatment.

Treatment should be individualized and evolve over time, drawing on the best available evidence. This includes not only evidence from clinical research conducted at the group level, but also the practical evidence that emerges from observing what actually works for a particular individual.

The Goals of Bipolar Disorder Treatment

Bipolar disorder treatment presents particular challenges because acute mood episodes are often what bring individuals into treatment.

Someone experiencing depression may reach out for help because they are suffering and wish to feel better again. For individuals experiencing hypomania or early mania, however, the situation is often different. These states may feel subjectively positive, which can make it difficult to recognize the need for treatment. Nevertheless, elevated mood states often produce dysfunction in a person’s environment, and eventually the individual—or those around them—may seek help.

It can be tempting to disengage from treatment once mood returns to baseline. However, treatment in bipolar disorder is not only about managing acute mood episodes. A central aspect of treatment is prophylaxis — the prevention of future mood switches.

Avoiding Depriving Oneself of Helpful Treatments

Providers should not deprive patients of treatment approaches that may complement care or prove beneficial. At the same time, a patient cannot simply demand that a provider work outside the domains in which they feel professionally competent.

For this reason, it is entirely reasonable for a person to work with both a psychiatrist and a psychotherapist, particularly when the psychiatrist does not provide psychotherapy as part of their practice.

At the same time, patients should also be mindful not to deprive themselves of helpful treatments.

Many people have understandable concerns about psychiatric medication for bipolar disorder. Taking a medication every day may feel burdensome. Some worry that medication will change who they are, impair their functioning, or create a permanent dependency. Others feel uneasy with the idea that their subjective experiences might be reduced to something that can be addressed with a pill. They may want to feel understood and therefore reject medication treatment altogether.

Psychological treatment can raise its own concerns. Engaging in psychological work often requires examining oneself closely, reflecting on one’s experiences, and confronting difficult emotions. For some, this may create the impression that all responsibility for change falls entirely on their shoulders. Some may reject psychological treatment altogether and ignore that, despite having bipolar disorder, they are still people and are not immune to life stressors and challenges. They may instead insist on medication changes at every encounter, in pursuit of a hypothetical “perfect pill.”

Both concerns are understandable, and it is important to work through them with time and patience, clarifying what needs clarification and gradually working toward a treatment approach that adds to one’s life rather than allowing bipolar disorder to interfere with the pursuit of personal goals.

In Summary

Bipolar disorder treatment requires individualized psychiatric care.

An individualized treatment involves finding a balance that respects both the biological and psychological dimensions of human experience. It also requires time—time for careful assessment, time to observe how a person evolves over the course of treatment, and time to develop strategies that support long-term mood stability and well-being.

The goal of treatment is not to force an individual into a predetermined framework, but to gradually construct—together with the patient—an understanding of their bipolar disorder and a treatment approach that is both clinically useful and personally meaningful.

— Helder Araujo, MD, PhD