Person-Centered Therapy as Applied to Work With Transgender and Gender Diverse Clients

Abstract

Scholars continue to call for research-informed treatment approaches for transgender clients. The existing literature directs therapists to learn about unique issues facing transgender individuals and to provide affirming therapy for transgender clients. We offer a person-centered approach to treatment for transgender individuals that integrates current scholarship with person-centered theory and offers specific interventions for use with transgender clients. These theoretical applications and interventions are offered for both interpersonal and intrapersonal work with clients. Following our analysis, we offer future areas of emphasis for treatment and research.

Keywords

person-centered transgender gender diverse therapy theory

Person-centered therapists who are interested in providing competent person-centered services for transgender and gender diverse individuals may already possess many of the tools and baseline insights that underlie competent care (Ehrbar, 2004). However, therapists may be unaware of how to apply their skills to work with transgender clients. Furthermore, practitioners may have cultural biases regarding gender that inadvertently shape the delivery of psychotherapy (Ehrbar, 2004). Professional organizations and scholars offer recommendations and guidelines for treatment providers who wish to offer competent services to transgender individuals (American Counseling Association, 2010; American Psychological Association, 2015; Koch & Knutson, 2016; Willging, Salvador, & Kano, 2006). These guidelines are offered alongside manuals that outline treatment recommendations intended to govern therapy with transgender individuals such as Affirmative Counseling and Psychological Practice With Transgender and Gender Nonconforming Clients (Singh & dickey, 2017) and Affirmative Counseling With LGBTQI+ People (Ginicola, Smith, & Filmore, 2017). Yet the volumes of work that have been produced regarding competent care for transgender individuals may fall short of providing actual interventions and specific methods for internalizing and reproducing recommended treatment standards.

Throughout this article, we use transgender to refer to “a broad array of people” who share a “discordance between their designated sex at birth and their gender identity” (Ginicola et al., 2017, p. 184). We recognize that gender diverse individuals (e.g., people who identify as nonbinary, gender fluid, and so on) may or may not: identify as transgender, socially and/or medically transition, or conceptualize gender in terms of male and female (Ginicola et al., 2017). Because of the wide range of possible experiences and life goals of gender diverse populations, the approach outlined in this article may have limited usefulness with some gender diverse clients. Thus, we use the term “transgender” throughout to acknowledge that our approach may fit best in work with clients who identify as transgender.

In general, existing guidelines provide a broad framework for work with transgender individuals that includes two general imperatives: therapists must gain knowledge about the transgender community and must provide affirmative services (Ginicola et al., 2017; Singh & dickey, 2017). However, existing guidance stops short of providing systematic applications of these therapeutic essentials to work with transgender individuals. In other words, theoretical applications of these umbrella guidelines are sparse and limited. Thus, the bulk of current literature regarding work with transgender clients remains atheoretical or metatheoretical. Such broad recommendations may be difficult for therapists to implement in focused, direct ways.

Scholars have attempted to make up for this gap in the literature by applying cognitive behavioral therapy (CBT; Craig, Austin, & Alessi, 2013) and person-centered therapy (Lemoire & Chen, 2005) to work with lesbian, gay, and bisexual youth and adolescents, but they have not included transgender adolescents. Building on this work, Austin and Craig (2015) focused specifically on CBT with transgender populations and found that the core tenets of CBT may be applied to transgender clients within an affirming environment that directly addresses discrimination and inequality. In another example, Budge (2013) utilized the middle stages of interpersonal psychotherapy to work with a transgender individual in the early stages of coming out.

Yet these applications too have followed the framework of encouraging awareness and affirmation presented in the more general guidelines offered by other scholars and professional organizations. Lemoire and Chen (2005), in their application of person-centered approaches to work with lesbian, gay, and bisexual clients, noted the uniqueness of issues faced by transgender individuals, and called for more information on person-centered work with transgender individuals (Lemoire & Chen, 2005). Chavez-Korell and Johnson (2010) answer this call with an integrative approach to therapy with transgender clients, but their contribution is both multitheoretical and brief. Budge (2013) offers an interpersonal approach to working with clients who are coming out, but her model narrowly focuses on one aspect of the broader experience of transgender people. As of yet, a broad application of a singular theory to work with transgender clients that takes into account both the developmental trajectory and the full scope of challenges faced by this population is lacking in the literature.

Person-Centered Therapy

Person-centered therapy may be particularly useful in work with transgender clients, given the fact that it may work “particularly well with people who are ‘different’” from societal norms (Raskin & Rogers, 2000, p. 156). Person-centered therapy is also recommended for work with individuals and groups in conflict, which is defined as the difference between the authentic identity of the individual and the values of others or of society that the individual has internalized (Raskin & Rogers, 2000). Considering recent calls for therapists to empower clients to take the lead in therapy, Person-centered therapy’s central focus on a client’s perceptions and feelings about self is particularly useful (Chavez-Korell & Johnson, 2010; Ginicola et al., 2017; Raskin & Rogers, 2000).

Brammer and Ginicola (2017) note that the World Professional Association for Transgender Health (WPATH, 2011) Standards of Care (SOC) 7th version underscores a “flexible client-centered approach.” In fact, person-centered therapy may provide a useful framework for understanding and integrating existing literature and scholarship regarding transgender people. Meanwhile, as society continues to grapple with transgender issues (exemplified, e.g., in current conflicts over bathroom access), a method that allows for less dependence on others for approval, by inspiring self-affirmation for example, may pair nicely with calls for affirmative and empowering forms of therapy (Ginicola et al., 2017; Koch & Knutson, 2016; Raskin & Rogers, 2000; Singh & dickey, 2017).

Thus, we will attempt to provide guidance on the benefits and specific applications of person-centered therapeutic interventions for transgender clients. We will begin by applying person-centered theory as outlined by Raskin and Rogers (2000) to the experiences and difficulties faced by transgender individuals both interpersonally and intrapersonally. Then, we will provide specific applications of the theory and interventions that may be used in therapy. We will close with a discussion of supplementary theories and approaches that may be used to augment person-centered work with transgender populations.

Theory

Though scholars offer approaches to transgender-affirmative counseling, these recommendations remain atheoretical and/or amount to a call for affirmative therapy performed by practitioners who are informed by present literature (Ginicola et al., 2017; Singh & dickey, 2017). As a supplement to the work that has already been done, here we will demonstrate parallels between the theoretical underpinnings of person-centered therapy and developmental experiences of transgender clients.

Impact of Discrimination

Austin and Craig (2015) call clinicians to an awareness of the “magnitude and effect of transphobic discrimination and on the lives and experiences of transgender people” (p. 22). For transgender people, the traumatic impact of discrimination may be experienced both interpersonally (e.g., being fired from a job, called transphobic names, or getting kicked out of one’s family’s home) and intrapersonally (e.g., self-harm, negative self-talk; dickey, Singh, & Walinsky, 2017). Interpersonal trauma may be experienced both globally (between the individual and broader society) and locally (between the individual and family members, partners, and/or friends; Brammer & Ginicola, 2017). We address interpersonal and intrapersonal dimensions of the experiences of transgender people separately in the sections that follow, integrating current scholarship where appropriate.

Interpersonal Impact

Marginalization and stigma for transgender people in the United States may arise, at least in part, from nonconformity to socially assigned or constructed gender roles that are based on heteronormative, cisnormative, and binary expectations regarding gender identity (Brammer & Ginicola, 2017). This nonconformity may result in almost daily experiences of microaggressions, transphobia, and discriminatory treatment that foster minority stress among transgender people (Austin & Craig, 2015). Minority stress may lead to maladaptive attempts to cope (e.g., use of nonsuicidal self-injury) and to the adoption of internalized negative self-beliefs that are absorbed after repeated exposure (Austin & Craig, 2015; dickey et al., 2017).

Raskin and Rogers (2000) discuss a process of development by which the structure of the self is formed as a result of “evaluational interaction with others” (p. 142). Over time, the individual introjects the values of others, but these expectations become distorted as they are “incongruent with the structure of the self” (p. 142). This is the case for people in broader society who are unable to escape the impact of rigid gender norms. The impact of masculine norms on men, for example, has been well documented (Synnott, 2009). For transgender people, the internalization of gender norms, transphobic ideas, and gendered values may be particularly troubling. These internalized norms may never be fully integrated because they are incongruent with the person’s core identity. Thus, the incongruence of a transgender person’s core identity and societal expectations or demands may generate significant levels of distress that are expressed more noticeably among members of this population, but that affect society at large.

Interpersonal relationships may further exacerbate the pressures and norms that can create a sense of distressing incongruence within transgender people. This may occur prior to and even after coming out if individuals are rejected after they reveal to others their core identity. Scholars have noted that the experience of gender dysphoria as well as treatment and diagnosis have societal dimension (Winters, 2005). Within the context of person-centered theory, family, friends, and broader society may both be the source of and/or magnify feelings of incongruence.

Identification as transgender may lead to a variety of issues with family and friends (Brammer & Ginicola, 2017). Transgender individuals can experience a variety of losses that have occurred in the past or that these individuals fear will occur in the future. For example, individuals who present for therapy may have lost family, friends, or partners, or custody of their children (Brammer & Ginicola, 2017). They may also anticipate a wide range of losses (Grant et al., 2011). For example, individuals may worry about losing their jobs, being expelled from their churches, and/or losing their homes (James et al., 2016).

Experiences of loss, both actual and expected, may lead to grief and other negative emotions (Brammer & Ginicola, 2017). Person-centered therapists may be uniquely positioned to sit with their clients in the unsettling reality that the road ahead will be difficult, but that the shape and specificity of that difficulty cannot be known in advance. At the same time, given the authentic connection that occurs in therapy, the therapist may be affected by the unknown and upsetting dimensions of reality as well (Ehrbar, 2004). Given the history of loss or rejection, or the fear of loss that transgender clients may have, it is important for person-centered therapists to process and appropriately manage their own reactions in a way that further strengthens, rather than places in jeopardy, the connection with the client. For example, suggesting to a client that the therapist is overwhelmed or in some way incapable of handling the client’s experiences may alienate the client.

In general, clients’ pervasive negative emotions are important to consider in person-centered therapy because emotion guides behavior (Raskin & Rogers, 2000). In as much as transgender people strive to avoid pain, they may hide aspects of themselves or may resist coming out in an effort to avoid negative emotions associated with loss and disconnection from others. However, this avoidance of one form of emotional pain (loss) may lead to another emotional pain generated by incongruence (dysphoria). Person-centered theory provides unique insight into the competing motivations behind self-disclosure and the unfortunate double-bind of the coming out process for transgender people.

Intrapersonal Impact

One major intrapersonal source of distress is gender dysphoria. The American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders–Fifth edition defines gender dysphoria as “the distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender” (American Psychiatric Association, 2013, p. 451). In this definition, there are echoes of the person-centered definition of psychological maladjustment: a “lack of consistency” between “an individual’s sensory and visceral experiences and the concept of self” (Raskin & Rogers, 2000, p. 146). In other words, a dissonance between the individual’s physical self and the individual’s internal self may lead to psychological distress (Raskin & Rogers, 2000). However, having an experienced or expressed gender that is different from one’s sex assigned at birth is not inherently pathological and should not be viewed as such (WPATH, 2011). Instead, person-centered therapy facilitates recognition of the challenges of transgender identity rather than denial or distortion of these issues, and assists with integration of a more authentic identity, with awareness that this identity may be rejected by others.

Intersectionality

As noted by Crenshaw (1991) in her discussion of marginalization experienced by women of color, individuals may possess multiple marginalized identities that intersect in unique ways. The impact of compound oppression on transgender people is evident in analyses of health and resource access disparities (Brown & Jones, 2016; Grant et al., 2011). For example, one national survey found that job loss, unemployment, and instances of police harassment were higher for most minority transgender racial and ethnic groups when compared with White-identified transgender people (Grant et al., 2011). Thus, the experience of a White, able-bodied, transman in a diverse, urban area may be very different from the experience of a Latinx, undocumented, transwoman in a rural area of the United States. For this reason, it is important to remain mindful of the complex ways that discrimination may affect transgender people with multiple marginalized identities.

Conceptualizations of the Person

In this section, we summarize ways that the transgender person may be conceptualized within person-centered theory. This overview is, by no means, exhaustive or the only way that the theory may be applied, but it may serve as a starting point for understanding person-centered approaches to gender diverse individuals. Though this section is divided into intrapersonal and interpersonal dimensions, these domains are often difficult to distinguish from one another because the social and internal experiences of the individual dialogue with each other. Overall,

Rogers (1951) conceptualizes the endpoint of all personality development “as being a basic congruence between the phenomenal field of experience and the conceptual structure of the self” (p. 532). The difficulties that arise from experiences of minority stress, discrimination, transphobia, trauma, and dysphoria can result from societal rejection and not inherent to identifying as transgender (WPATH, 2011). Dysphoria, negative emotions, and other issues are not essential components of transgender identities. In some cases, after the layers of societal norms and expectations have been peeled away, individuals may have more clarity about the steps necessary to bring themselves to a greater sense of congruence. This is an individual, intrapersonal process and the individual should be seen as the expert on their own identity and as a person in relationship with others (Chavez-Korell & Johnson, 2010). Not all sources of dysphoria are societal, but society may have a large influence on levels of dysphoria experienced by the individual (Winters, 2005).

Within this context, it is important to remember that “gender is based on one’s subjective sense of self” (Brammer & Ginicola, 2017, p. 188). Brammer and Ginicola (2017) point out that gender terminology is ever changing and adapting and that each individual uses labels or terminology that feels authentic given the person’s unique internal experience (Brammer & Ginicola, 2017). Thus, therapists should not assume that they know exactly what a term or identity category means for an individual client. Instead, clients should be empowered to tell the story of their own identity.

Interpersonal Self

Like other human beings, transgender individuals seek acceptance both from broader society and from family and friends (Brammer & Ginicola, 2017). The difficulties and discrimination faced by transgender people may lead transgender individuals to hide dimensions of their past and present identities from others (Brammer & Ginicola, 2017). This process may be intentional and thoughtful or the client may be only marginally aware of all of the ways they are striving to fit family and societal norms. When clients choose not to disclose aspects of their identities for well-thought-out reasons, (e.g., in an effort to set healthy boundaries, in order to ensure their physical safety) the toll of any associated incongruence may be lower. Still the energy expended to manage one’s identity may produce some stress for the individual.

To the extent that withholding information about the self represents subconscious self-rejection in an effort to connect with others, it may foster psychological maladjustment as the individual “denies to awareness significant sensory and visceral experiences” (Raskin & Rogers, 2000, p. 143). This denial of the self may happen both externally, when a transgender person dresses or presents as a gender that they do not identify with in order to avoid rejection, and internally, when presentation as a gender that they do not identify with leads to a rejection of their own needs. The overlap of internal and external self-rejection may make the two impossible to distinguish from one another. Greater congruence in presentation, self-understanding, or expression, and increased acceptance from others leads to psychological adjustment and a reduction in stress and strain (Raskin & Rogers, 2000).

Intrapersonal Self

In person-centered theory, individuals are conceptualized as whole, coherent beings rather than fractured compilations of intersecting identities (Raskin & Rogers, 2000). Thus, as individuals become able to identify what is important or authentic for them, they are able to dismiss or part with unnecessary behaviors, stressors, and/or identities. Experiences or pieces of feedback that are inconsistent with the authentic self may present themselves as threats to the coherence of the individual and may, therefore, lead to psychological distress. The demand to live or present inauthentically on a daily basis is one of these threats to the congruence of the transgender person that conflicts with what Raskin and Rogers (2000) called the person’s “internal frame of reference” (p. 145).

The WPATH (2011) SOC 7th version indicates that reconciliation between one’s gender identity and one’s gender presentation results in reductions of gender dysphoria or the dissonance created when one’s gender identity does not match the sex one was assigned at birth. This assertion is powerful when viewed in light of the actualizing tendency principle, which states, “given a free choice and in the absence of external force, individuals prefer to be healthy rather than sick . . . independent rather than dependent, and . . . to further the optimal development of the total organism” (Raskin & Rogers, 2000, p. 145). One possible move toward congruence for transgender people is referred to as transition and may reconcile incongruence and establish greater psychological consonance.

As individuals begin to accept themselves more, they may also be free to more clearly identify their needs regarding their physical bodies. The WPATH (2011) SOC 7th version suggests that clients may need assistance fostering congruence between their identities, their societal presentation, and their bodies. The context of therapy can provide clients with a safe space to openly and candidly talk about their bodies. Person-centered theory reminds us that the body is part of the whole person who seeks congruence (Raskin & Rogers, 2000).

Goals of Therapy

Austin and Craig (2015) assert that transgender-affirmative clinical practice “must counter the oppressive contexts in which transgender clients often experience health and mental health care.” (p. 22). When considering treatment from a person-centered perspective, this response to oppressive systems and contexts may be extended to interpersonal and intrapersonal dimensions of the client’s experience, both within and outside of health care settings (Raskin & Rogers, 2000). However, this process of countering oppression via person-centered therapy may not be overt or directive. Rather than taking the active role of psychoeducator and vocal advocate, the therapist serves as a “respectful companion in the typically difficult exploration of another’s emotional world” (Raskin & Rogers, 2000, p. 135). This process is client-led and involves psychological contact between the client and the therapist (Raskin & Rogers, 2000). In this way, the therapist takes an empowering stance that redefines transgender-affirmative clinical practice as the opening of a space in which the client is able to self-actualize through a process of “reduced defensiveness and of self-directed expansion of self-awareness” (Raskin & Rogers, 2000, p. 141).

Interpersonal Goals

As mentioned earlier, according to Raskin and Rogers, (2000) the person-centered therapist serves as a “respectful companion in the typically difficult exploration of another’s emotional world” (p. 135). In other words, the person-centered therapist embarks on the journey of discovery with the client. Though the therapist partners with the client and remains sensitive to context, the therapist may also possess insights and awareness of resources and scholarship that may prove useful to the client. Scholars have called for therapists to actively seek out information about transgender communities and to learn as much as possible about transgender lives (Chavez-Korell & Johnson, 2010; dickey et al., 2017). Therapists who work with transgender clients may be more effective if they educate themselves about the process of and/or options for social, legal, and medical transition in the United States and within their local state. Therapists who provide therapy for transgender individuals may be a source of resources, referrals, and may foster opportunities for interpersonal connections and community building (Koch & Knutson, 2016).

Given that so much is still unknown about gender diversity, therapists may be fearful about whether they will be able to learn all of the terms, characteristics, or components of the ever-changing and developing world of gender identity outlined by Brammer and Ginicola (2017). Where gaps in knowledge exist, person-centered therapists are encouraged to continually educate themselves and to challenge their own assumptions (Ehrbar, 2004). Person-centered theory recognizes the limitations of the therapist’s knowledge and allows for a journey with the client that empowers the client to identify the components of their own identity (Raskin & Rogers, 2000).

Intrapersonal Goals

Person-centered therapy recognizes that a client’s feelings and self-perceptions are at the core of client concerns (Raskin & Rogers, 2000). This approach differs from CBT approaches that target clients’ flawed thinking about the self (Austin & Craig, 2015). Rather than working to overturn individual beliefs about value or worth, the therapist works to create an environment in which the client is able to experience the sort of acceptance and unconditional positive regard that is lacking in other dimensions of the client’s life (Raskin & Rogers, 2000). Once a more open and affirming environment has been experienced by the client, the client may seek out and/or cultivate similar environments in their own life with the confidence that such environments exist and that the client is worthy of participating in an affirming world.

Core to the person-centered approach is an awareness or trust that individuals “can set their own goals and monitor their progress toward these goals” (Raskin & Rogers, 2000, p. 134). Along these lines, the person-centered therapist understands that transgender individuals know what they need to thrive. Use of person-centered therapy may allow individuals to become less dependent on others’ transphobic, discriminatory standards, may cultivate resistance to introjection of these negative values, and may encourage the formation and cultivation of more congruent and authentic values that allow the individual to accept and affirm the self (Raskin & Rogers, 2000). It is hard to overemphasize the importance of opening a space for transgender people to be fully themselves with all of their intersecting identities, cultural contexts, and unique interests. Put simply, transgender individuals may thrive when given the space to simply be complex and human without judgment of their humanity.

While clients may benefit from direct psychoeducation regarding ways that discrimination and trauma have led to feelings of disconnectedness proposed by Austin and Craig (2015), clients may benefit a great deal more from coming to these realizations and conclusions themselves (Rogers, 1951). This approach identifies the client as the expert with regard to their own life and experiences (Chavez-Korell & Johnson, 2010). It is possible that the antidote to a society that tells transgender people they are unacceptable is not simply a therapist who tells the individual they are acceptable, but rather, a client who discovers their own worth. This self-discovery and self-empowerment is the goal of person-centered therapy with transgender clients.

Specific Recommendations and Applications

According to dickey et al. (2017), transgender affirming mental health care includes the following components: recognition of multiple, intersecting cultural and sociopolitical contexts affecting the client; interventions that address the influences of social inequities; enhancements of resilience and coping; social justice and advocacy; and an approach that empowers the client or emphasizes client strengths (Chavez-Korell & Johnson, 2010; dickey et al., 2017). These components (e.g., recognition of context, positive focus, and empowerment) are hallmarks of person-centered therapy as well (Raskin & Rogers, 2000).

Creating an Open Environment

As suggested by dickey et al. (2017), therapists may wish to display “visual cues that affirm gender” in their clinics and offices (p. 47). They may also wish to introduce themselves to clients, offering their pronouns along with other pertinent information about the therapist’s gender identity or experience treating transgender clients (Austin & Craig, 2015). Austin and Craig (2015) offer a script for introducing the clinician’s identity as a transgender-affirmative advocate.

While too much therapist self-disclosure may impede the therapeutic process, clients may feel safer if they know that their provider has knowledge, experience, and an appropriate grasp of the therapeutic process. Clients may come to therapy with internalized transphobic thoughts and may struggle with religious and/or moral questions that they find deeply unsettling. Highlighting one’s transgender-affirmative approach will not necessarily cause a client to feel “pushed” toward transition or to come out prematurely. When clinicians share limited biographical information and context, this can demonstrate to clients that the therapist is knowledgeable and able to “accept and respect their clients’ ways of thinking and perceiving” (Raskin & Rogers, 2000, p. 137).

Therapist Self-Awareness

Person-centered therapy involves use of self and requires that the therapist provide a nonbiased environment to the greatest extent possible (Raskin & Rogers, 2000). To facilitate such environments, therapists may benefit from exploring their own gender identities with as much depth and dimensionality as possible (dickey et al., 2017). Ehrbar (2004) encourages therapists to clarify their own biases, gaps in knowledge, and prejudices. Person-centered therapy not only provides space for congruence on the part of the client but also assumes that the therapist will work toward greater congruence as well and will serve, in some cases, as a model of congruence for the client (Ehrbar, 2004). Toward this end, it is very important for therapists to explore their own internalized transphobia, biases against gender diversity, and the impact of gender norms in their own lives.

However, Brammer and Ginicola (2017) caution against clinicians using this insight as a guide for understanding their clients. Core to person-centered therapy is an awareness of the separation between the clinician’s own identities and biases and the world of the client (Raskin & Rogers, 2000). To the degree that therapist self-exploration facilitates a deeper and more healing connection with the client, it may also benefit the therapeutic process (Ehrbar, 2004). However, therapists would be ill advised to engage in therapy solely to increase their own awareness and cultural competence. The therapist’s self-understanding is important to provide culturally competent services, but is not a goal of therapy. The goal, rather, is to cultivate self-understanding in the client that, in turn, facilitates further self-directed growth in the client (Raskin & Rogers, 2000).

Bracketing

The importance of affirming the client’s self-report cannot be understated. While clinicians may know the typical progression of symptoms or therapeutic processes, they should not criticize (either implicitly or explicitly) clients who are not forthcoming about all symptoms, diagnoses, or interpersonal patterns (dickey et al., 2017). The same applies to clients who may over report symptoms. When writing letters, providing documentation, or rendering diagnoses, the multiple dimensions of the client’s context should be considered (dickey et al., 2017).

One example of a point at which bracketing would be useful is during the process of writing a letter supporting hormone replacement therapy. As noted earlier, the appropriateness and process of diagnosing transgender people with gender dysphoria has been hotly debated (Winters, 2005). Therapists may possess a variety of perspectives, thoughts, or feelings regarding the provision of a diagnosis for transgender clients. However, clients may have their own feelings about gender dysphoria or other diagnoses being included in a letter to a physician. In the context of person-centered therapy, the inclusion or exclusion of such language may be left up to the client and therapist biases may be bracketed.

Client Guided Process

When using person-centered therapy, it is important for the client to determine the direction of therapy (Raskin & Rogers, 2000). While therapists may desire to provide psychoeducational interpretations of the client’s adaptation to discrimination and mistreatment as the reason for psychological and emotional issues (Austin & Craig, 2015), this interpretation runs the risk of alienating the client from their own experience and of reducing the client’s work in the here-and-now of the therapy setting (Raskin & Rogers, 2000). Instead, the therapist is encouraged to unconditionally accept the client’s current state of being or the present emotional state of the client (Raskin & Rogers, 2000).

Taking an Immersive Stance

Raskin and Rogers (2000) encourage therapists to make “a maximum effort to get within and to live the attitudes expressed [by the client] instead of observing them, diagnosing them, or thinking of ways to make the process go faster” (p. 147). For person-centered therapists, true empathy is characterized by a therapist’s “sensitive immersion in the client’s world of experience” (Raskin & Rogers, 2000, p. 147). This may be a particularly powerful intervention for clients who have experienced rejection both interpersonally and intrapersonally.

Avoiding a Problem-Centered Focus

The diagnosis of gender dysphoria is saturated in a long-standing discussion surrounding the benefits and problems associated with conflating identity and diagnosis (Winters, 2005). Additionally, diagnosis may be inherently problem-focused. In contrast, person-centered therapy focuses on the client rather than the problem (e.g., gender dysphoria, self-harm, etc.). This focus recognizes that transgender identities are not inherently pathological. Furthermore, maladaptive coping skills and/or negative emotions that transgender individuals exhibit may be conceptualized as symptoms of an underlying interpersonal or intrapersonal incongruence affecting the person (e.g., rejection, discrimination, discomfort with one’s body) rather than the problem itself. For example, focusing on self-harm as a problem to be solved is less productive than exploring ways that internal and interpersonal incongruence may have produced the drive to regulate emotions through self-harm (Walsh, 2012).

Mock Transcript of Work With a Client

Here, we draw from our clinical work with transgender clients to provide context for what a client-centered session may look like. This dialogue is intended to acquaint the therapist with the overall process of therapy. The interaction that follows was not drawn directly from case notes or from a solitary session.

T1:

Alright, now that we’re settled in, what would you like to focus on today?

C1:

Well, I’ve been feeling pretty crummy this week. My mom has been insisting on calling me by my birth name and she threatened to kick me out of the house if I don’t start wearing “appropriate” clothes. I almost cut last Tuesday, but I was able to stop myself.

T2:

I notice myself cringing as you describe your mom’s behavior. I wonder what you are feeling?

C2:

That’s just it. I’m not feeling anything. I’m feeling hollow. But I know I need to feel. That’s why I almost cut last Tuesday. I needed to feel something.

T3:

It appears that you are experiencing some of that emptiness right now.

C3:

Yes, I feel alone. Like I’m on an island and I’m the only one. Like there is no one to reach out to.

T4:

Like you’re isolated . . .

C4:

Yea, and I am isolated. People don’t get it. They don’t understand.

T5:

No one understands like you do . . .

C5:

I’m not sure I even understand me. It’s like I can’t figure out what I expect of myself when everyone else wants stuff I can’t give. I can’t be that person, the person they want me to be.

T6:

Sounds confusing . . .

C6:

Yea, I wish I could just silence all of the voices. I wish I could just be me.

T7:

There is a you, underneath it all.

C7:

Of course! I just need someone to accept that.

T8:

To accept you . . .

C8:

Yes.

T9:

I wonder if you accept you?

[PAUSE]

T9:

I want to. I think I do. At least, I want to.

T10:

I see a look of resolve on your face.

T10:

Well I think it’s worth trying to accept myself. You seem to accept me. At least I don’t have to worry about feeling empty here.

Analysis of Mock Intervention

In the transcript above, we illustrated: therapist self-awareness, bracketing, client-guided process, taking an immersive stance, and avoiding a problem-centered focus. The therapist begins by inviting the client to direct the therapy session at T1 and notes at T5 that the client is the expert on their own experience. At T5 and at other critical junctures, the therapist allows the client to select the next step and to build on the content in the therapy session.

The therapist also brackets judgments or interpretations regarding the client’s experience. At C1 and C2, the client notes feelings of dysphoria and an impulse to self-harm. Rather than reacting to the self-harm and negative emotions in an evaluative way, the therapist focuses on the emotion and isolation behind the client’s self-report. Of course, it is also important for the therapist to assess risk and address it if appropriate, but here the therapist allows the client the opportunity to discuss their desire to cut in a nonjudgmental environment.

Throughout this brief transcript are examples of the therapist’s immersion in the therapy session. The therapist offers feelings and observations through appropriate self-disclosure at T2, T3, T6, and T10. The therapist engages in use of self to offer the client insight into the client’s own process and to affirm the client’s experiences.

The therapist also manages to avoid a problem-centered approach. Rather than focusing on gender dysphoria or self-harm, the therapist focuses on the client’s experiences, thoughts, and emotions at T2 and T3. Underlying these interventions is an awareness that the client’s feelings of isolation and rejection of the client are expressed in negative emotions or in the inability to feel at all.

One principle that is not explicitly showcased in the transcript is therapist self-awareness. Self-awareness is required to appropriately engage with the client in a nonbiased way and to understand the impact that the client’s parent’s behaviors may have on the client. The therapist’s ability to make use of other person-centered interventions rests on their self-awareness.

Supplementary Suggestions

As suggested by many scholars, transgender individuals may benefit from resource lists and case management (Chavez-Korell & Johnson, 2010). These scholars call on therapists to “facilitate access to appropriate services” such as legal resources, medical professionals, and social support networks (Chavez-Korell & Johnson, 2010, p. 210). Scholars have offered a variety of therapeutic interventions that are not directly called for by person-centered theory, but may be incorporated as needed. For example, bibliotherapy, narrative reauthoring, trauma-informed interventions, discussions of power differentials, use of a Hope Box, and worksheets are tools that may be used to supplement a person-centered approach (Austin & Craig, 2015; Chavez-Korell & Johnson, 2010; dickey et al., 2017). While using these interventions, we encourage therapists not to lose focus of the collaborative process inherent to person-centered therapy. Wherever possible, it is best for clients to retain an active role in the therapeutic process and to determine whether and how they would like to participate in the activities outlined above.

Conclusions

Clearly, person-centered therapeutic approaches mesh well with existing literature regarding mental health treatment for transgender individuals. Person-centered theoretical conceptualizations of human development account for interpersonal and intrapersonal psychological challenges among transgender people. Person-centered interventions allow for focused treatment of rifts within the individual that are internalized from societal rejection.

As the call for empirically validated treatments grows, more research will be needed to establish the efficacy of person-centered work with transgender people. Given that previous studies have established some equivalency between therapeutic approaches, further research may demonstrate that the core components of person-centered theory underlie effective transgender-affirmative therapies (Imel & Wampold, 2008). Researchers may benefit from further investigating ways to boost these existing skills by coupling them with an awareness of transgender-affirmative resources that facilitate social, legal, and medical transition. Continued work toward providing specific guidance regarding clinical interventions and procedures for practitioners is warranted.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Douglas Knutson

Author Biographies

Douglas Knutson, PhD, is an associate professor in the Department of Psychology at Southern Illinois University Carbondale. He received his BA in theology and ministry and in English literature from Southern Illinois University in 2006; his MTS in philosophy, theology and ethics from Boston University School of Theology in 2008; his MEd in applied behavioral studies with professional counseling from Oklahoma City University in 2012; and his PhD in educational psychology-counseling psychology from Oklahoma State University in 2017. His research interests include sexual orientation and gender identity diversity with a focus on transgender health.

Julie M. Koch is an associate professor and head of the School of Community Health Sciences, Counseling and Counseling Psychology at Oklahoma State University. She received her BA in Japanese language and culture from the University of Massachusetts in 1992; her MEd in educational psychology-school counseling from the University of Texas in 2001; and her PhD in educational psychology-counseling psychology from the University of Minnesota in 2008. She is an licensed health service psychologist in the State of Oklahoma and is a former public school teacher and school counselor. Her research interests include microaffirmation, counselor training and development, faculty competence, social justice, and multicultural counseling.

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