Key Principles for Therapists Working with Trans Clients with Dr. Stephanie Budge

Dan is joined by Dr. Stephanie Budge, Professor and the Director of Clinical Training in the Department of Counseling Psychology and at the University of Wisconsin-Madison. 

In this conversation, Dr. Budge discusses her journey into the field of psychology, focusing on bisexuality and the need for better mental health support for trans individuals. She shares her experiences in academia, the challenges faced in researching LGBTQ+ topics, and the importance of trans affirmative therapy. Dan and Dr. Budge discuss essential terminology, the ethical considerations in therapy, and practical advice for therapists working with trans clients, emphasizing the need for understanding, practice, and balance in therapeutic relationships.

Special Guest: Dr. Stephanie Budge

Practice with Pronouns

World Professional Association for Transgender Health Standards of Care

GALUP: The Gender Affirming Letter Access Project

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Chapters

• 0:00 Introduction
• 2:00 Dr. Stephanie Budge's Journey into Two-Spirit, Trans, and Non-Binary Mental Health
• 7:00 Understanding Key Terms: Trans, Two-Spirit, and Non-Binary
• 12:30 Challenges in Academia and Researching Trans Mental Health
• 18:00 Defining Transgender Affirmative Therapy
• 23:00 Common Mistakes Therapists Make and How to Avoid Them
• 28:00 Overcoming Therapist Anxiety in Working with Trans Clients

Transcript

0:00

[Music] Broadcasting from the most beautiful city in the world, I'm your host, Dr. Dan Cox, a professor of counseling psychology at the University of British Columbia. Welcome to episode number 39 of Psychotherapy and Applied Psychology, where we dive deep with the world's leading applied psychology researchers to uncover practical insights, pull back the curtain and hopefully have some fun along the way. If you find our show helpful or interesting, it'd be much appreciated if you could share it with someone you know who might enjoy it too. It's a great way to spread the word and keep the conversation going. Today I couldn't be more excited to welcome one of the world's authorities on two-spirit trans and non-binary mental health. My guest is a professor in counseling psychology at the University of Wisconsin-Madison, and some of her honors include several from the American Psychological Association, including multiple early career awards, a Distinguished Contribution Award, a Social Justice Award, and a Transgender Research Award. She also has several awards from her university, including an Exceptional Service Award, and a Community Engage Scholarship Award. In part one of our conversation, we discuss several aspects of two STNB mental health, including transgender affirmative therapy, principles for therapists working with trans clients, overcoming therapist anxiety with trans clients, navigating naming pronoun practices, and much more. This episode starts with my guest responding to my question about how she got into studying two-spirit trans and non-binary mental health. Throughout further ado, it is my pleasure to welcome my very special guest, Dr. Stephanie Bunch. When I was first admitted to the doctoral program at the University of Wisconsin-Madison in psychology, I was really interested in studying bisexuality, and that was part of my own experience in coming out as a bisexual person, and learning a little bit about the mental health processes of that, of identifying as a bi-person, and what's included in that. And I think a lot of students kind of start off this way with this research piece. Right, research is research. Yes, which I think is great, and I think it lends to a lot of exploration personally, but also then motivation to continue that work. So that's actually what I was starting off doing, and doing some work with sexual orientation more broadly. And then in one of my classes my first year was taking a career counseling class, and I'm in the textbook, trans people weren't even mentioned at all, and we were supposed to give a presentation on a particular career counseling topic, and so I had asked if there were any trans people who'd be willing to kind of talk to me about their career-related processes so I could talk to the class. And so I had this like amazing conversation with this trans community member for two hours about his career experiences, and we were wrapping up. And then Annie Heath said, you know, I thanked him for cheering with me, and I was excited to share this with my class, and he said, you know, I just gave you two hours of my time. There is something that I want you to do for me, and I was like, okay, this is, you know, I was like 24 years old, you know, I'm like, yes, like what can I do? And Heath said that all of his experiences with therapists had been awful, and he said, you know, you are actively in a position where you can make things different for psychologists. I think you should make therapy better for trans people. And I was like, okay, great, you know, like no big deal, like not a big ask at all. But I actually, I took it really seriously because I thought, well, like here's this human I'm sitting across from who has actually like shared with me a great deal of his experience that I can help educate these other people who are learning how to be mental health providers. And yeah, I took the task very literally that changed my trajectory of my career and my life. I think that, you know, I share this when people ask me like, how did you get interested in this? And I think part of the other interesting piece is that I'm a cis person, so I'm a cis queer person. So I'm still like involved in the broader LGBTQ community. But I'm not trans. And like I didn't interrogate this career path at that moment about like what it would be like being a cisgender person, entering into this field of that I had no knowledge of and also wasn't my specific community. So I will say like I've been through that process now to be able to think about what that means. But at the time, I just kind of move forward without really thinking critically about what that would mean. What kind of stuff generally did he say like what was his experience in therapy? You know, we didn't talk that deeply about it. I think I did obviously ask them follow-up questions, but he said, you know, that therapists didn't really understand trans people that he felt like he was misgendered a lot or just that therapists seemed uncomfortable with talking about gender and therapy. And it's interesting if you read any of the microaggressions literature related to psychotherapy and trans people, basically all his experiences that he described mapped on perfectly with what you see as the themes being that people generally experience, trans people experience from from therapists. Okay, so I think we're going to run into this a lot, which is I think at least at the beginning, it's just like terms and that we're going to have people who are listening, who are going to be like, I've heard that term, but I'm not exactly sure what that means or, you know, so we've used the word trans. Can you help unpack what that means? Yeah, you know, I think some of this is more colloquial versus what we academically. And I think academically, I would say two-spirit trans non-binary and we would say two-stnb, I might use that also when I'm talking, but I think trans colloquially is like perhaps what we say when we're just having conversation with people. But I would say the reason why we want to use kind of the broader language is that in general, I think when we're talking about this two-spirit trans non-binary community, it's people who don't ascribe to or identify with the sex that they were assigned when they were born and with the societal expectations that come along with that gender assignment. And there are some really unique components related to being a two-spirit person, for example, which is, you know, being an indigenous person and the indigeneity that's related to like the cultural components of gender, which is a little bit different. Like when we have worked with indigenous people and communities, they've asked us to center and have two-spirit be first when we talk about identities, which is why we say two-spirit trans non-binary because they felt really erased, which is also, you know, just in general, what has happened to indigenous people. So, you know, but two-spirit can be a term that encompasses several different things, so it doesn't have to just be gender identity. It can be sexual orientation. It can be a lot of different pieces that are related to kind of this fluidity and identity as well. So it's an important term that we use that we include first, but particularly because indigenous people have been really erased in the gender narrative. But for trans people, we usually say that can be, you know, really anybody who identifies with a gender that's different from the sex they were assigned when they were born and then for non-binary people, that could include non-binary people, but we also say non-binary separately because some non-binary people wouldn't say that they're trans necessarily, but non-binary people, when we think about that term, is often like somebody who doesn't identify on the binary of male or female or as a man or woman. Okay. Yeah. Okay. So some of these terms are, can I say this? Some folks might say I identify in more than one of these, or some folks would say, no, no, I mean, this one specifically. If we say, and I'm just talking colloquially here, that like, and you've already said this, but just sort of paraphrase, I guess, or restate like that, when we're in this conversation, when we say either two STNB or trans or sign it, just talking about folks who don't their identity, their gender identity, is not the same as the sex in which they were born. Yeah. The sex that was assigned to them when they were born. Yeah. Thank you. Sex they were assigned. All right. Okay. So I think that'll give us enough to at least have a reasonable conversation. Although I'm sure that somebody's going to be like, oh, but you forgot this nuance because I'm sure there's lots of nuance that we're forgetting, but we could probably have, I'm sure we could, well, you could write books on the topic. Okay. Great. So the other thing that you said was cis. Could you say what that is? Yeah. So cisgender is the term that we use for people whose gender identity matches or is an alignment with the sex they were assigned when they were born. So I use that term because I was assigned a female sex when I was born, and I identify as a woman. Got it. Okay. Okay. So what was that like when you sort of had this, okay, I'm going to take this seriously, and I'm going to do it? What was that like, what was the reception from people in your, say, academic training world to your saying, like, I want to do this? That's a good question. I think in general, I think people were supportive of the exploration of this path. I did get specific messaging from professors and mentors saying, you can't just study this group though, because you're not going to be able to have a career in this. And that's actually why I ended up studying and learning psychotherapy research kind of as a as its own field, because that was specifically what I was told you need to do something else more general if you want to be marketable as an academic. Obviously that's not true. That's I didn't know that at the time. I was kind of following the advice and taking two different paths, but I also felt like I was I love psychotherapy research and I love learning about the science of psychotherapy. And I knew that at some point I wanted to do psychotherapy research that was related to LGBT people in general, but more specifically trans and non-binary people. So I think it wasn't the wrong path, but I think the messaging that I got around it was incorrect. At the time. Being that it was saying like you like don't hyper focus. Yes. Yeah. And I think there was a fear around me getting a job and me being employable if this was something that I was going to be focusing on, which I just this is kind of my personality. I just didn't care about that. I thought well like this is seems this is really important. It's important to me personally, but also like I don't know. I don't know if you have people swear on this podcast. It was like fuck academia. Like if they don't, if they don't want science related to an entire group of people, then we'll like figure it out elsewhere. And that was sort of the implicit or maybe explicit message was that this isn't like doing science on this on trans folks is not enough. Yes. But I mean, I think you know this was in the I will say, you know, this is some there's some age related stuff involved here that I was getting trained in the 2000s. And I was even getting messages around, you know, be careful about coming out in, you know, as a queer person in your job interviews and kind of thinking about like when I'm writing my internship essays, should I even like talk about this really openly. So I will say I think that there's been even the last, you know, 15 plus years, there's been a shift in advice related to these sorts of things. Of course, dependent on the site and personal, the person's personal desires. But I think I also when I was being trained, none of the faculty in my program did anything related to LGBTQ people. So I also think there was perhaps you know, like just a lack of knowledge around what it might look like in our field to do to do this work. Yeah. And so, so I think it makes sense to sort of delve into you've developed some work on doing psychotherapy with trans folks. And you developed a sort of I've done some RCT work looking at different inventions and these sorts of things. And so, you know, in our conversation, I would love to you know, talk about perhaps some of those specific studies and experiences. But also, you know, you've done a lot of work with human beings and psychotherapy outside of those studies. And I'm so I'm curious, you know, also about, you know, those other experiences and integrating that into this. So, but one of the things I thought would be useful to start with is in, you know, in one of the RCTs that you're a part of that you have a you had a treatment group and a control group. And the control group, you ended up calling transgender affirmative therapies. That's the control group, right? And so, it's like your approach was a treatment as usual and then a treatment as usual plus. But you called the treat, but treatment as usual, you're like, yeah, this is more than just treatment as usual. So, let's call it transgender affirmative therapy because there's more built in here. And I was wondering if you could, if maybe it would make sense to sort of start off with you describing a bit about what transgender affirmative therapy, what that means, what that looks like. Yes. I'm trying to think if I want to answer your question, but I also want to provide more context. Go for it. Provide more context. And then if you don't answer the question, I'll come back to it. So, I'll go. Okay. Yeah. Well, maybe just provide some, you know, when we were first designing the RCT and having conversations, we talked with community members, trans community members specifically about the design of the project. And the main piece of feedback that we got initially was do not include a wait list. Like that is demoralizing. We do, if you include a wait list, people will feel really upset about this. This is feedback from the community members. Mm-hmm. Yeah. And so, because initially, I think we were thinking, oh, we'll do, you know, this very typical, you know, we want to follow this gold standard way of designing RCTs. And especially when we're thinking about, you know, a treatment that people haven't really looked at before, let's, you know, you would do a wait, you know, a wait list. And then you would try this new treatment that you're thinking about. And it was interesting because already the initial feedback that we got was do not do that. People will not want to participate, and they'll feel really demoralized. And so, and especially, I think, part of the conversation around the ethics of, there is, you know, that people who are to STNB experience a lot of distress. And I know that you might have some questions about minority stress kind of in subsequent parts of this podcast, but, and of thinking about that the experience of oppression does increase the rates of depression anxiety, but specifically, you know, suicidal ideation and suicide attempts, and so kind of thinking about the pretty high rates of suicidal ideation and suicide attempts and thinking about the ethics around a wait list. And what that means when you can have a provision of a mental health treatment. So, just to say, we have lots of conversations about the ethics of a wait list and what that would mean and what that would look like. So we thought for sure, the control group needs to be some type of treatment and some type of treatment as usual. So we're like, great, we'll just, you know, when we initially were designing this, we were really interested in having a minority stress intervention and an intervention that really addresses oppression and psychotherapies. That was our goal. And so when we started designing the treatment as usual, we said, great, we'll just have, you know, therapists in the community provide, you know, there, there be that they normally provide. Then there was a question around like, but what if they microaggress the clients? And like, what if all these, all this information that we have about the things that therapists are doing wrong, is it also ethical to then just like send clients into a scenario where that's the case? So we had lots of conversations about this. Like if we're actually interested in oppression and that's kind of what we're trying to figure out how to address in a psychotherapy context, if you're sending clients into a situation where they might experience oppression from the therapists, like we're not even going to be able, how do we even measure the experience? So then we thought, well, all the therapists have to be trained then in like how to not microaggress clients. And that's a very reductive way of talking about trans-affirmative therapy. But in the, in the very least form, it's like training therapists, how to make sure that they have like a basic level of competence regarding language to use and basic level of comfort in the topics and also in kind of understanding and and and having information about different processes of like social transitioning or medical transitioning, things like that. So general trans-affirmative therapy is just what I would call more of like a basic level of competence and knowledge information and skills that therapists have in one working with trans clients. So if you were talking to just like the average therapist and you were, we're giving a training or workshop or whatever and sort of you had to pick three things I'm making that on number up that are like, hey, these are the three things that you want to make sure to either not do or do. What would those be? Yes. Okay. There are three three's arbitrary. So you can you can make it two, you can make it eight like whatever. Yeah. Yeah. I would say, I mean, this is like the most basic. It's so interesting when you see people talking about this, which is like don't invalidate your client's identity, believe them, like trans people exist. You know, like this is kind of the most basic that a lot of the microaggressions literature says that therapists will say things like there isn't there isn't a diagnosis for gender dysphoria in the DSM. Like they don't even have an idea that there is like anything in the DSM that's related to gender identity, for example. It's a different story around diagnosis and gender dysphoria. That's a conversation for another day, but I think, you know, just a basic not even like having the knowledge that there's even anything in the DSM, for example, like that's one thing. And kind of as an extension of that, just say, you know, that I don't believe you in that your identity and I don't believe that trans people exist, right? Just what does that look like? Like I don't understand. Like what does that look like? Is it an extremely naive question? Yeah, well, I mean the executive order that was just passed in the US on last Monday, which is the you know, the first day that that Donald Trump was in term says basically that trans people don't exist. I mean, it says, you know, we only define gender and sex based on, you know, well, I mean, I'm not even going to get into the definitions I have, because they're actually incorrect the definitions that they provide, but it's based on conception and what happens with an egg and a sperm when they come together and what happens from sex differentiation, basically. But I think the basic premise is that trans identity isn't real and that trans people don't really exist and that they're all in general going to desist at some point or go back to assist gender identity. So like this is a phase. And not even, I mean, I think that there's, I think that there are gradients of this, you know, I think. So I'm talking about maybe a more extreme version. But I think that, yeah, I think on the most extreme version is you don't understand really what's going on for you. Like you're interpreting what's happening to you internally as gender identity, but it's something else like a trauma reaction or something else. Oh, interesting. Okay. Okay. So, okay, so I interrupted you in terms of the handful of things that you would make sure to like cover. Yeah. And I think actually the majority of therapists don't do that, but some do, right? You're going to have a spectrum of the way that people react to identities in lots of different ways. But I would say for the majority of people who don't have a lot of training, it's mostly just they're worried about making a mistake. You know, they're worried that they're going to mess up with pronouns or with a name or not know or say something wrong, and that they're going to offend their clients. And therefore, what trans clients say. And I think this is just clients in general who experience marginalization and therapists are nervous about like messing up that, you know, that clients can sense that feeling of like, you know, if therapists are like really tiptoeing around topics or if they're like withholding themselves a little bit, you can pick up on that. You can feel that. And it feels like a barrier in the alliance. So I think trans clients talk a lot about this feeling that they get from the therapists that the therapist is worried about making a mistake and therefore just seems like reserved. So that's another thing. I would also say, you know, therapists will often also say, you know, like, I don't have training in this. So like, I can't help write this referral letter for you, for example, like instead of actually seeking out the training or getting some of that education, they'll say, like, I can't help you because I don't know how to do this. And that can feel really upsetting from an access to care standpoints. I can keep going, but those are a few things that so getting back to that warrior anxiety and sort of like tiptoeing around something like when you have, what would you say to that person? I mean, there's probably a lot of therapists who are, you know, aware and sort of like, I'm like, I'm just so worried about saying the wrong thing or, you know, and in a way, although it might, you know, result in, you know, having negative implication for therapy, that's not at least in our little example here. That's not coming from a bad place, you know, it's coming from a caring place. It just unfortunately can impede their therapy. So what do you say to that therapist? Yeah, oh, we tell people to practice, you know, what is it that you're really worried about messing up? Because a lot of times, you know, if it's, oh, I'm just worried I'm going to say like the wrong name when somebody, you know, changes their name in the course of therapy. And so one example that we have for people is that if you are in a group practice where it's okay for you to share confidential information, to really like spend a lot of time consulting with your colleagues while you're using the new name, for example, because that way, if you make some mistakes, it's with another person and that won't offend the client, right? But that it's, it literally is just practice and this happens to all of us, you know, I, I have to do this as well. It's a cognitive shift when someone changes a name or pronouns. And so I think that most of it actually is just getting used to the process. And the best way to do that is, like I said, if you're in a situation where you can share confidential information like you're in a practice with colleagues where you can do that, but that's an example. If you're practicing using pronouns, we say like practice with your pets, you know, like practice, like there are things, practice in different situations where you can get more use to set of pronouns that maybe you're just not as used to using. There are these really great apps online where you can practice pronouns. And you can practice all sorts of different ones. You can even type into Google just like pronoun practice. And at the end of this, I'm happy to send you a few. Yeah, yeah, yeah, I love including resources for the description. Yeah. Yeah. So I think most of it actually is just the cognitive process of getting used to is getting used to making those shifts and changes. We don't really use pronouns with clients because we're typically talking to them rather than about them. So I would say probably the, it would be the name if you often use a name like when you're talking to clients. If you don't typically do that, those things often aren't as much of an issue. I think it's just an internal fear or worry. But also when you're charting, you know, like that's also a way to practice with new names and pronouns as well. And that doesn't impact the client. So these are, I think, things that just to maybe know that you will get a lot of practice with it. And there's some intentionality that you can do to get to getting practice in. I think you have to get okay also with like you might mess up. And so you have to be okay with, you know, apologizing and then how do you, how comfortable do you feel managing that rupture. And what trans clients will say just like in most ruptures is that you don't, you don't want to over-apologize that actually like trans clients say like when the mistake happens, which most people, especially trans people, I think expect that they are going to be some mistakes, some mistakes at the beginning. And that it's, it's like, yeah, like you're learning, you know, that's fine. And trans people make mistakes with their own names and pronouns, but themselves too in the beginning. So like a lot of this is kind of just getting used to it. It's more just, you know, I think what the clients who I've worked with will say and what I think research participants will say is like if it's prolonged, that's a problem. It's like if we're in the beginning and we're just kind of trying to figure it out, it's more normative. And it's great if you want to say I'm so sorry and then you move on. But it's like when it becomes a problem is that the therapist then over focuses on the mistake and then keeps on apologizing and wants to process it. And it feels like the burden is on the client. Yeah, that's sort of as you were talking and then you sort of went right there in terms of ruptures. I was thinking about like where is, I often think about, you know, bringing, like if there almost any clinical challenge, you know, often the answer is bring it into the room, right? Like just like let's just bring it into the room, you know, and because your reaction, you know, if when your client says something a certain way, you experience a little bit of fear of that person, there could certainly be therapeutic value and bring it into the room. And like where that line, if that line is different when it comes to gender identity, then it does for other. Yeah, I think this is just true across the board for identity related stuff. This isn't true just for gender, but I think it's more like, if it's a lack of competence on the therapist's part, I don't think the client wants to hear about that. So like, you know, this is just kind of, I think most clients, regardless of their identities would say, well, learn about it, you know, like, like figure it out, like learn about it. I think if it's if it's a rupture that happens between the two because that isn't competence related, then I think you talk about it if that makes sense. I think you can still acknowledge it as a therapist to be totally, I think you can say, you know, like, you can apologize when you make mistake and say, you know, like, it's on me. I'm, I've already have a plan for how I'm going to learn XYZ. So it's not on you, but I am going to work on this. So I think it's fine to kind of share a process with somebody without putting it on them. But I think that it's more like, are you processing your lack of knowledge with a client? You know, like, what does that do for the client? And what kind of a burden does it place on them? This isn't just for, you know, yes, TMB people. Yeah. Right. No, I think that's a good rule of thumb. And I think it's important to get like, this is like a general rule of thumb. There are exceptions to these things, but thinking about like overly processing my lack of knowledge or competence is, is a rule of thumb, and probably not so useful. It might, what it might be, you know, asking a couple of, tell me if I'm wrong here, asking a couple of clarifying or knowledge-based questions, and then perhaps assigning yourself homework, but not to just keep pursuing that in session with the client. Mm-hmm. Yeah. And I think that clients can tell, like, it's okay. We're never going to know everything about every human being or about all groups of people, and we're all going to mess up, you know, so I think that these are things to kind of think about. I think it's more, what do you do with that when you start to realize, okay, yeah, this is, I really need to get some, some more education about this particular thing. And I think it's a little bit harder in situations where people have like 30 clients a week, you know, and I think sometimes some of this, there might be systemic challenges to getting that education that are just part of the problem, honestly. Right. Right. But yeah, but I would say it's, I think that part of the part of what I think trans people talk about in the literature, and what I've heard my clients share with me, is that what's the problem is that they feel like sometimes, you know, therapists either, like, they will overemphasize stuff related to gender, because they want to show that they're really into it, and the client will be like, no, I was just talking about like needing to change, you know, like figure out how to like fix my toilet, you know, like it's not related to my gender at all, but that therapists like wants to demonstrate confidence, and so they're overemphasizing. But then also therapists will also under emphasize, and that causes anxiety for therapists, because they say, okay, so the literature says therapists over and under emphasize gender, and that those are both problematic, like how do you find the balance? And what we did in the treatment as usual, in the transformative therapy training for both groups was we actually practiced with the therapists this dynamic. So to actually name that this is a dynamic that happens in therapy, you know, like just so you know, I, you know, your gender is an important part of who you are, I might ask you some questions about it, but I'm not always going to be talking about it, especially if it doesn't seem relevant, but you know, like let's try to find that balance together. So for the intervention side of it, you have the transgender formative therapy, and then you also added on this building awareness of minority related stress component as well. Could you tell us a bit about that? Yeah, so we, for all of the clients who were randomized. That's a wrap on the first part of our conversation. As noted at the top, doing much appreciated if you spread the word to anyone else who you think might enjoy the show. Until next time.[Music]