Companionship Over Compliance: Rethinking Mental Health Support for Trans Communities with Dr. Stephanie Budge

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

Part two of Dan's conversation with Dr. Budge delves into the complexities of minority stress, particularly for transgender individuals, and the therapeutic approaches that can help mitigate its effects. The conversation moves to the importance of psychoeducation, the role of internalized stigma, and the innovative frameworks like radical healing that aim to empower marginalized communities and the evolving nature of referral letters in the context of informed consent.

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Chapters

• 0:00 Introduction
• 1:19 Minority Stress
• 6:06 The Role of Psychoeducation in Therapy
• 16:00 Internalized Transphobia and Mental Health
• 21:07 Addressing Internalized Stigma in Therapy
• 29:02 Letter Writing for Trans and Non-Binary Clients
• 35:05 Challenges and Support in Trans Research

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 40 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 the show useful, it would be much appreciated if you shared it with someone else who might enjoy it too. Today, I couldn't be more excited to welcome back one of the world's authorities on two-spirit, trans and non-binary mental health. My guest is a professor of 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 this part of our conversation, we discuss several aspects of Trans Mental Health, including Minority Stress, the role of psychoeducation, internalized transphobia, the companionship model of letter writing, challenges in doing trans-related research, and much more. This episode begins, with my guest talking about an intervention for attending to Minority-related stress with trans clients. So without further ado, it is my pleasure to welcome back my very special guest, Dr. Stephanie Budge. For all of the clients who were randomized into the BAMS group, we had a tool that was called the Minority Stress Tool that we provided to them where there was an entire psychoeducation component before therapy even started, where we talked about, here's what Minority Stress is, we provided definitions of it, we talked about examples of how that happened in therapy or just happens in general for people, and then we asked them to give some examples of things that they would like to talk about in therapy. And so based on that, we were trying to help provide some psychoeducation on the language and naming the Minority Stress is something that exists, but there's also even more data now than there was at the time when we were getting this ready that externalizing the problem is really beneficial to being able to help reduce distress for trans people. Like, oh, there's an actual label for why I'm experiencing this. I had no idea. And that's actually what people would say when we were going through this tool. They're like, why hasn't, why have I never heard this before? I'm like, it's game changing, it's life changing to hear that there is an actual concept to describe what I've been experiencing. So that happened before psychotherapy even started. So we did the psychoeducation session and then they started psychotherapy. And then the supervision was focused on using this Minority Stress Framework and then before every session we had clients fill out measures like they typically do in psychotherapy research, but we also for the Minority Stress Group we said, list up to three Minority Stress Events that happened over the last week and let us, and as a way of thinking about if you want to talk about them or not. But we did tell people you don't have to talk about Minority Stress in the therapy. You don't have to talk about these three things that you're listing out. It's not a requirement. You get to talk about what you want to talk about in therapy. But I think the main difference was that they got a psychoeducation. They were thinking about some of these factors as they were going into each session and the therapists were trained specifically in the framework both before and then during the intervention. So what is Minority Stress? Yeah, good question. So there are a couple of scholars who kind of talked about this term. So Virginia Brooks in the 1980s and then Ilan Meyer in the 1990s and then thousands specifically started talking about Minority Stress related to lesbian gain bisexual people. And the way that they had talked about it was that there are reasons why lesbian gay bisexual people experience higher rates of distress and depression, anxiety, other things. And the two primary factors that they theorized that were involved in that were distal stress, which are kind of these external things that happened to you related to your in this instance sexual identity. So things like discrimination, harassment, bullying, rejection, those kinds of things are distal or external stressors that happen that are directly related to that and increase in depression, anxiety, other types of distress. And that there are these proximal or internal stressors that happen to that are internal to the person that are also related to distress. So those internal processes are things like expectations that discrimination might happen or expectations of rejection, concealing your identity, internalizing stigma as a way of believing that there is something internally wrong with you and inherently shameful about you and that there's a direct relationship from those things also to increased distress. In 2012 Michael Hendrix and Ryle and Testa extended that framework to focus on trans and on binary people. And then this kind of in the last decade, there's been a kind of an explosion of research that has been testing this framework because I kind of simplified it but there are also lots of paths that are focused on coping, for example, and resilience and stress factors and community and different kinds of things that are also in the model that are that scientists are testing. So it was so what you were saying that the clients just by learning about this, just sort of psychoeducation about this, they sort of had some aha moments. Yes and it's so it's interesting because then if you're thinking about the mechanism of change for psychotherapy, you're like is it the psychoeducation that happened prior to the therapy even starting or was it that in addition to the psychotherapy, was it the psychotherapy because interestingly enough, like both groups improved but there was more improvement in the BAMS group, it was specifically related to internalized transphobia. And that was a question that I was going to ask, sort of like what were the what you thought were like the the minority stressors that were most relevant important? Yeah, so I think that internalized transphobia one was the one that stood out to me the most because that one I think if you're really you know when I think about what we have control over as therapists, we don't have any control over the distal stress that people experience, right? We if people are experiencing rejection, harassment, bullying, victimization, you know the only control we have in the one-on-one therapy room, this is individual therapy, is to talk with them about that experience and empathize with them, perhaps provide them with some coping skills related to that. But I do think we actually in psychotherapy, we have more of that ability to focus on that internalized stigma, which is really what a lot of the supervision was about in in that group. So it makes sense to me that that was an outcome that was a targeted outcome that we were testing and that demonstrated bigger gains for that group. So what is internal internalized transphobia? It's that I was kind of defining it a little bit ago, but it's that taking in those external messages that you're getting and believing them basically that there's something wrong with me, my identity isn't real, am I really trans? Trans people are bad, you know it's basically all these messages that are happening from an external perspective, you are taking them in and then you believe them and internalize them as being true. So stuff that like the I shouldn't be or I should be or it's not okay for me to or I am wrong about that around their gender identity. Exactly. Okay. Okay. So when you're like okay so the folks in the BAMs, the intervention condition, they got they got this training at the outset and then in the training but then weekly I believe they were sort of prompted to come up to I say like were there any of these minority stressors that happened to you over the last week and if so do you want to talk about them in therapy, right? Is that about right? Yeah, well it's mainly they could list out up to three minority stressors that they experienced over the week and then they were the therapist could prompt for that at the beginning of therapy. Is that something you want to talk about today or not? So that was the process. I will say and I don't know if this is you know maybe interrupting you from your question but the clients did not like filling out the weekly minority stressors prior to therapy and that was something we wrote up a paper about the minority stress tool and this was feedback that we included in that paper where we said they really liked the tool but they did not like filling out the weekly minority stress events. I don't understand what you mean they liked the tool but not filling out like you mean the tool you mean the thing at the outset that they did. Yeah, they found out of all of the pieces that were related minority stress for them they said they really really appreciated the tool. We got a lot of positive feedback about the tool and being able to have something tangible that they could take with them that they used that information outside of therapy when therapy had terminated but that they founded a annoying to list out what their minority stress events were from the previous week. So what's your takeaway from that? You know I got it. I feel like that was feedback that made sense to me. I think you know when you're designing psychotherapy, when you're designing any research you know that there are going to be components that you won't do again and I wouldn't do that part again based on the feedback. I don't actually think that that was helpful to them. It didn't seem like I think the goal in mind was to prompt people so that they were thinking about it prior to going into therapy and we were really priming people but it's but it makes sense that you know if it's important it's going to come up anyway and also perhaps the techniques that are being used around helping to reduce internalized stigma and helping with coping skills related to this kind of external stressors that are happening that can all happen regardless of of priming people for the minority stress events that they had over the week. I also just think it was distressing to clients. I think that we were priming them for to describe something that was highly distressing and people didn't like that and there are perhaps other ways to do that. So like was it were they filling it out like at home or wherever they were before they came in or they filling it out in the waiting room? They filled it out in the waiting room. Oh that's interesting that so like where I you know I've worked with where we used like you know outcome assessment you like the outcome questionnaire 45 and stuff like that and people fill it out in the waiting room and I always felt like my experience with clients was that as long as you like brought it into the session even if only briefly like they didn't mind they're sitting in the waiting room anyway. So it takes three minutes you know once you do it a few times so that's interesting then that they didn't like it you know what I mean? Right well they filled out the OQ 45 at the same time as well and they did not say that they didn't they they we did not get the same feedback about that. Really? But they did not like filling out the working alliance inventory so you know we got a lot of feedback about the measures that we used in the trial. This was you know I would say it was a pilot study and so we were really thinking about this from a feasibility perspective and gave a lot of information for the next clinical trial that we were going to do but I think yeah so people didn't mind filling up the OQ 45. Okay okay okay so I mean if would you then because it seemed to be like part of the BAMS intervention was right I mean there's the train I'm part of the idea was behind it was like let's give the opportunity let's sort of open the door to this conversation and that was one of the goals for having them fill out their minority stress experiences weekly as I read it or interpreted it. Would you still try to do that like if you were to like would you have therapists instead maybe just bring it into the conversation routinely like it? Yeah I think it's more the conversation and actually this did impact because we did another study that focused on also people being able to talk about oppression and psychotherapy after this about a much larger scale and we did not do any prompting of any type of oppression based experience and the survey that they took prior to starting that therapy and so we did take that feedback into account and I do think when we were training the therapists and the in the next clinical trial it was more around how are you talking about this we're going to provide you with you know with this subsequent one that we did was focused more on radical healing and more specialized interventions for internalized stigma based on the information we'd had and this CT that we've been talking about and it seemed like just from getting the feedback that we got from the trial that clients were less annoyed by the measures and things that they had to fill out ahead of time and we and the effects were even stronger in this next trial that we did for improved mental health. So I you know I think part of it is this is what we always do right this is science you you have a hypothesis right you think things will work you try it out you get feedback and you adjust and you change based on the information that you receive. So what were some of those interventions for internalized stigma? The ones that we used in this trial yeah so um Dr. M. Matzuno and Dr. Tanya Israel created an online intervention that focuses on internalized stigma for trans people specifically so they have it it's a four module online intervention that they created and so what we did is we took the four online modules that they created from their study and we adapted them for psychotherapy and so there are a few different things the people can do one is the process of externalizing which we've talked a little bit about already. The second one is kind of some interventions that are focused on self-compassion so those are things like they're the in the online intervention that the participants would read a scenario where there's transgender youth and they would write a letter to that youth to say like you know hear the things that you can kind of hear the things from my own personal path that have that have worked out or things that that maybe you could anticipate so it's basically writing a letter to youth about the kinds of things that can work out in the process of being a transgender person so it's kind of that process of giving advice to somebody else and then you read your own letter and like how do you internalize that information for your own self because I think the idea here is that it's so much easier to have compassion for someone else and to give advice to other people but it's so much harder to believe that so these are just a couple of examples and there's also in the online modules there's a lot of information about like positive psychology and trying to create spaces for joy and resistance and so that's another component that's included in it but those were just a few things that we talked about we really focused on using the radical healing framework that French at all it's a French there are a bunch of people who are part of this radical healing collective who've created this framework and we consulted with two of the people from the radical healing collective to help guide how we train the therapists in our next study. So what is radical healing? It's a good question it's a really big framework there's a lot of information in it I would say the very first article that has been that was written about this in the more recent years so like I said it's French at all it was I think counseling psychologist is what was published in 2020 and it's specifically for people of color and it's interesting because I think for our next clinical trial that we did it was for trans people of color and so we were really talking to the developers of this framework around how do we adapt the radical healing framework that we really primarily focused simply on people of color to also include like a gender perspective and both of the people who we had consulted with do LGBTQ work as well so they were able to help guide us in thinking about how do we actually think about this framework for two-spirit trans non-binary people of color and there are a few components that are included in the framework but I would say the things that we focused on the most specifically are things like critical consciousness so in therapy how do you actually help clients to be able to become active-change agents and to feel a sense of empowerment so that's like one piece strength and resistance is another component radical hope is another piece that's included in this framework and and collectivism and community and but the idea behind those radical healing framework is the dialectic holding a dialectic with clients around saying it's not just like sitting in the oppression and it's not just like saying everything's going to be fine but it's this idea of saying we're going to hold the fact that you experience oppression and talk about the reasons why while also talking about this concept of kind of radical hope and helping you to hold both at the same time and so we spent a lot of time trying to figure out how to incorporate these concepts for trans people of color. Okay so one of the things that as you were talking about internalized stigma that I wanted to ask you about based on for you having thought about this for years that like how do you or how is it like qualitatively different from like internalized beliefs about other types of things sort of like other I should I ought kinds of statements that you know often shop obviously in therapy. Yeah I mean I think that probably the cognitions look the same from from my perspective they probably look the same but I think that from a cultural perspective the messaging is different right so I think most of these most of that kind of internalization of shame in any way is culturally based right. I think the flavor of experiencing it because of like marginalization does seem different because it's like the power the power systems that are involved and who who gains in those instances and who doesn't right so like people who have more power are not going to have that internalized stigma they're not going to have that that's not going to impact them at all and therefore they're always going to be advantages to them because they don't have to manage that. Okay yeah that make I mean I think that makes sense sort of this idea of like a lot of those the beliefs there's a lot of similarity in terms of shame related beliefs but that if we think about where they come from and how that what that looks like at the implications of it in the world like almost outside of the self it is different it is unique. Right because literally anybody can experience like what you're describing as kind of these greater cognitions around like I shouldn't be like this or you know that can impact any human but to me the difference is this will only impact the humans who are who are stigmatized in those very specific ways and therefore put them at a differential impact because we know that those kinds of experiences of internalizing stigma are related to more creator mental health impacts and lower quality of life. So okay so if we could take a slight left turn and I think that one of the things that folks are going to be interested in and you've talked about a little bit is letter writing for transgender non-binary clients who are considering medical intervention. I was wondering first if you could just sort of give us a very brief sort of lay of the land on you know what that is what that looks like. Yeah and I'll talk about my experiences all in a US based context so I can talk a little bit about that but that right now where I practice there are these letters called referral letters that basically either medical offices or insurance offices require of a trained mental health or medical provider to say that a two-spirit trans and non-binary person has the capacity to provide informed consent for gender-affirming medical care. Now that's my definition of it based on the World Professional Association for Transgender Health Standards of Care like the most recent guidelines. However I think historically these letters have been used in differently and continue to then be used in different ways because of misunderstandings around what the purpose of these letters is for. So what you said is very narrow at least how I heard it which is are is this person able to provide informed consent so is this person of sound mind I don't know if that's the which is a I mean I'm sure there's a lot of nuance in that but that is that's a pretty narrow question to ask right right yeah well and I think I mean I think maybe I think of this in terms of what what the capacity is of mental health providers right like we are trained to assess informed consent and like does this person can our clients actually provide informed consent that we do this with every single client who we see at the beginning of any type of assessment or clinical interaction that we have with them and especially in the beginning when we have our informed consent procedures but I think the how these letters have been used historically have been that there is a is basically gay keeping that there is a mental health provider or medical provider who says you're really trans or you're not trans or like you haven't thought about this deeply enough or you don't understand what this is enough or you don't have access to the types of resources that you need and therefore I don't think you're able to engage in this process so historically things like if you if trans people also had additional mental health concerns alongside the gender dysphoria that they were experiencing that might disqualify them for example from receiving gender-framing medical care or like there was this something that was called the real life test and if like the trans person hadn't like lived as their like current gender for a certain amount of time that they would not be approved to have gender-framing medical care so I think in the past actually I would say the way that these have been used and thought of have been less related to informed consent but that literally the way that they're talked about right now in terms of the guidelines is that our role and what our capacity is as mental health providers is to see can this person actually provide informed consent do they know how to have these kinds of conversations with their medical provider can they consent to these medical procedures when they're when they're having that conversation their medical provider because I can't assess for informed consent for medical yeah I'm not a medical provider if they if I ask them when I do ask them questions like what do you what do you expect the side effects are going to be because I think that that's part of the an important part of the process that we're supposed to do when we're writing these letters I do want to know like how much does this person actually know has their doctor educated them on this how much have they how much information have they engaged in but just but I I'm not the medical provider so if they don't know all the side effects you know and also I mean the other part of this is like I think of all the medical procedures I've ever had and like my level of knowledge into the side effects of the things that I've that I've had has been pretty minimal actually and so you know it's kind of trying to think about it's important to engage in these conversations but to what extent do we what's our expectation for what a patient should know prior to going in and talking to a medical provider versus after so this so I was under a false assumption about basically how you describe these as gatekeeping that was my understanding of what these were yeah so this is super helpful for me because I was wrong and this this framework of thinking about are you know just the informed consent piece of it is just that makes so much more sense to me and like when you're talking about what I hear what I hear you saying when you're saying like asking them questions about you know what do you expect the side effects to be what do you basic you're what I'm hearing you say is that you're assessing for very basic level of knowledge that would be reasonable for someone to give informed consent to do something right like if I and I totally agree with what you're saying but if you know it would be reasonable that you're if you're going in for some sort of serious surgery that the that you'll get information about like what the you know how long you're not going to be able to do what is going to be after the surgery what's the probability of success what's the probability of you know of dying what's the right there was very foundational things because that if you don't have that very foundational stuff then you can't you you don't have you you're not informed right so how can right so you want people to have that basic information yeah I mean I will say how do I want to talk about this I this is how I talk about referral letters and this is how our team talks about referral letters this is our understanding of the standards of care I think how they're actually used in my experience is more of a gatekeeping way and I think a lot of people are trained to use it in a gatekeeping way so I think your understanding it is probably more an alignment with how these letters actually often occur rather than the literal interpretation of like what the standards of care ask for and in fact in the standards of care letters aren't required it's it's more that insurance companies often require the letters or medical providers will require the letters and so therefore the client will need to get a letter from a mental health provider somebody who writes these letters and there are lots of information in the standards of care to say when you are doing an assessment with someone when this letter is happening here all the things that are important to do and like talk about fertility you know like but that's all part of like the informed consent but they have all sorts of things like you should assess for gender dysphoria you need to talk about fertility you need to make sure that you have all the qualifications that you need to be able to write these letters so I think when we write about this we write more around you know these sessions often feel highly invalidating for a lot of trans clients that it can feel discriminatory to a lot of trans clients because this is not a procedure that's required for many other medical care pieces for some there are you know there are some there are some components of medical care that do require a psychologist or mental health provider sign off like transplants and bariatric surgery things like that but I think the question for trans people is like why is this on the same level of that but in our writing about referral letters we say you know we're not we we're not going to comment on whether or not these letters should be written or not in our frameworks we say if you are asked to write a letter here's a framework to use to make the decision. Yeah and you talk about the companionship the companionship model and that's really what I wanted to get to those for you to sort of communicate with what that's about. Yeah so we you know we wrote an article about this companionship model which includes we say the acronym base so validating asking sharing and engaging and basically we provide a way to hopefully help the assessment session just feel more affirming for a client in a way of saying like how are you feeling coming in a lot of times clients are pretty angry that they need to come in so part of that is like validating those experiences talking with them about that not totally make sense or they're like I'm really excited to be here I can't wait then validating that you know so it's more like kind of assessing where the person's at for how they feel in relation to getting this letter and then also just we say you know like asking them about their own reactions to the letter writing process that the clinician can share their own feelings about gatekeeping and things like that with clients but at an appropriate level based on what clients are disclosing and then also engaging with them in a collaborative way with writing the letter and especially since clients if they're if they need to be in the session we especially say this is such a great moment to give clients resources and so really like if they're paying for the session especially most people do have to pay for these sessions like give them their money's worth you know like let's like think about how to connect them to different resources and different things they can get connected to we offer lots of examples of how to do that in the article yeah so it's a framework for making the interaction less top-down making it more frankly I hesitate to use the word therapeutic because it's not necessarily you're doing psych therapy or that's not necessarily your charge but there are some parts to that in the process and at the very least destigmatizing and not hurting the person in the process yeah exactly or just like sitting with them in a process you know I think regardless of your where your orientation is to writing these letters I think being able to sit with somebody and whatever and how they feel about the process I think can be really important so is there any pushback or any challenges that you want to talk about in relation to your work? yeah I mean oh what do I want to say about that I think yes doing work related to trans people right now is controversial where I live and across the globe right now so I think it kind of depends on pushback in general actually I found a lot of support at the university where work is incredibly supportive the community is incredibly supportive where I live so I would say actually the majority of my experiences are have been really positive ones and ones that have been with open arms and support and reasons why I've been able to do this work right like the places where I've worked have funded the research and so I think that in general I would say most of the experiences that I have had have been supportive I think they're have you know right now we have an NIH a big NIH grant that focuses on social support and there's some and certainty about federal funding right now and the US around trans related research and so I'm curious to see what's going to happen there I've also received you know things like hate mail to my office and trying to figure out like what do you actually do when that happens when you get like threatening mail what do you do yeah well I found out through this process that you need to report it as stocking at the university so I had to take pictures of it and send it in to the university I think anybody who's doing trans related work at the university is getting support related to like what happens if people do reach out if there are things that happen and yeah I mean I think just part of it is just trying to be prepared for that and also thinking about like the level of impact like I'm making these decisions to to do this work but like my wife for example and our kid like you know my wife worries more about this than than I do so I think part of that is kind of that having that orientation to like the decisions that we make and who that impacts in our family but also like thinking about the broader community as well so there is a lot of put there's pushback and I would say though the majority of the experiences that I've had have been incredibly supportive yeah yeah it's kind of fascinating to think about somebody like yourself resuming the work that you're doing and you have this other other dimension of challenge that most of us don't have yeah I mean it's so interesting because I think you know I think of the the researchers right now who I think who are doing this work who are incredibly impacted are people who are doing like vaccine related research who are you doing immigration related research who are doing climate change related research like there are pockets of us right now who I think are being particularly they're particularly heightened and it's incredibly stressful but I think any but anything anybody would say from the researchers who I work with would say you know this is we know that science is important and that being able to engage in the scientific process and being able to trust evidence based processes is incredibly important and we want to be able to be a part of that I also will say being a cis person who's doing this work that's also something like it doesn't impact me as much as it does the colleagues who are trans so right so one of the things I always like to do is sort of give an opportunity if there's any resources that you want to provide that here and then I can link into the show notes as well I mean there were a few things that I got so the app that you talked about the the guidelines in terms of letter writing I think would be super helpful but if there's anything else particularly if there's anything you know that you want to send folks to in terms of if they want to learn more about your work yeah I will send some information I also think there's something called the gallop which I don't remember what exactly that stands for and I'll send that along and I think it might be mostly focused in the US but it's a database of therapists who will write letters without cost in the US and perhaps it might even be extended from the US so also that as well ladies and gentlemen dr. Stephanie budge that's a wrap on my conversation with dr. Stephanie budge as I noted at the top of the show it'd be much appreciated if you could spread the word to anyone else who you think might enjoy the show until next time[Music]