Therapy

LGBTQ+ Person-Centered Therapy

Understanding empathy and empathic understanding.

Posted Jul 04, 2020

If you’re looking to integrate person-centered therapy (PCT) into your gender affirmative practice, pick up a copy of Sam Hope’s (2019) Person-Centered Counseling for Trans and Gender Diverse People: A Practical Guide. They do an excellent job mapping the plurality of the gender experience while also demonstrating some valuable “do’s and don’ts” of working with gender variant clients.

Sam Hope, who identifies as nonbinary, also observes how congruence, unconditional positive regard, and empathy cannot be fostered until the therapist addresses their own unconscious bias.1 And there are so many biases around sexuality and gender! A clumsy PCT 101 approach implementing the core conditions in good faith, without genuinely comprehending where the client is coming from, actually misses Carl Roger’s whole point.

Alex Stitt
Empathic understanding is the bridge back from isolation, alienation, and loneliness.
Source: Alex Stitt

Let’s get real, how many times have you heard: “Yeah, I used to have a therapist who’d just nod at me and ask me how I felt”? Even if we set aside novice practitioners, there are some truly excellent person-centered therapists fully engaged in the process who still struggle with LGBTQ+ clients!

This tends to happen when the general feeling of empathy is present in lieu of accurate empathic understanding—defined as the therapist’s ability to adopt a client’s frame of reference instead of their own so as not to distort the client’s meaning.2 This means gender affirmative PCT requires not only respect for all gender identities but also an informed, real-world understanding of each client’s respective experience.1,3,4 One cannot always be prepared ahead of time, which makes active learning and self-correction vital in any gender affirmative practice.  

Carl Rogers was meticulous when it came to self-examination, frequently reviewing the transcripts and recordings of his own sessions to map the subtle, almost imperceptible shifts in tone, attitude, or therapeutic direction. He did this because congruence, unconditional positive regard, and empathic understanding aren’t lofty ideals—they’re achievable being states felt within the session itself, and when they’re aligned, people begin to feel truly safe and truly heard. It can be difficult for cisgender heterosexuals to achieve a state of congruence with LGBTQ+ clients, but it’s by no means impossible.

Person-centered therapists typically do not talk about themselves or convey their own opinions, and Sam Hope cautions against clinicians trying to prove how competent they are. Indeed, a truly skilled person-centered therapist can convey congruence in silence. This isn’t magic; this is cultural immersion. When therapists get the micro-cues of body language, paralinguistics, code-switching, and the subtle nuance of inflection to hear what went unsaid—PCT becomes a powerful form of affirmative therapy.

Keep in mind that without knowing anything about a therapist’s personal backstory, sexuality, or gender identity, a client can pick up on a therapist’s ability to align with them. Ability is not the same as intention. Uniqueness, liminality, alienation, loss, grief, despair, hope, love, passion, and doubt are all part of a Queer breakfast, and it’s very clear when therapists would rather have Eggs Benedict.

It’s easy for a client to get frustrated with kind-hearted therapists relying solely on empathy because they don’t feel empathically understood; as such, the therapist cannot be wholly congruent. LGBTQ+ people often have friends and family who absolutely love them, but go glassy-eyed when a sexuality or gender issue comes up because they just can’t wrap their heads around it. Expecting this, many LGBTQ+ clients report holding back gender-related issues from their cis-hetero therapists, even if they like them.5,6,7,8.

So what does gender affirmative PCT look like?

Accruing my hours for licensure, I studied with Laura Moidel Acevedo, LMHC. She’s the kind of guitarist who combines Jazz and Hindi Raag, and the kind of therapist who shows her clients how to manifest their internal archetypes by making videogame avatars in session. She’s inventive, creative, and incredibly attentive, specializing in trauma therapy, gender and sexuality issues, and the dark shadows where they overlap. Laura taught me how a truly informed approach applies the appropriate therapeutic technique for the client’s needs. No doubt, I’ll talk more about her use of post-modern deconstructive modalities and Jungian archetypes in the future, but today PCT is our focus.

Out here on the Big Island of Hawaii, Laura has provided a safe haven for gender variant people in need of a therapist who actually understands what they’re going through, and she often incorporates both creative outlets and psychoeducation into her practice. Yet her use of PCT is profound. As a self-described woman of trans-experience, Laura doesn’t shy away from her transition story, as she knows how often Queer voices are erased. Even the loud and proud aren’t always sure who will truly understand them, so it’s not uncommon for LGBTQ+ people to conceal deep wounds even from friends and allies. Additionally, when we start to explore the uncharted waters outside of the gender binary, issues of doubt, confusion, and dysphoria can sometimes erode our ability to trust our own voices.

When done well, gender affirmative PCT can create a living embodiment of safety where (and I can’t stress this enough) one may have never existed before. We live in a world where LGBTQ+ minorities are not only told that our love is taboo, but so too our bodies, our thoughts, and our feelings. This can be difficult to articulate, which is why therapists need to hear what goes without saying or is too complicated to be said. This isn’t an existential riddle, though it can certainly feel that way.

To achieve this level of congruence requires an intimate knowledge of the client’s world, including their familial, racial, ethnic, and spiritual culture, and how these integrate or splinter with their sexual or gender identity. As the LGBTQ+ community isn’t a monolith, this can sometimes mean one’s “competency” is rebooted with every new person who walks in the door. There is, after all, a massive difference between the spoken and unspoken code of butch lesbians from the Pacific North West, and those of a Gen-Z enby teen in Texas. So as not to tax the client, gender affirmative therapists constantly have to explore diversity outside of the session, which is a tall order, but a fun one, too.

Both Sam and Laura’s ability to align with their clients is certainly informed by their life experience, as is everyone’s, but it’s their ability to actively learn in the present moment that’s the real key. Being on the receiving end of a poorly executed person-centered approach can feel like sitting in an echo chamber with a lot of awkward silences feigning to be deeper than they really are. But when the clinician deeply understands the world that we’re from, either because they themselves are a part of it or an active ally to it, then PCT becomes a direct route to validity. 

References

1. Hope, S. (2019) Person-Centered Counseling for Trans and Gender Diverse People: A Practical Guide, Jessica Kingsley Publishers, Philadelphia, PA. 

2. Rice, B., Moon, A.K. (2017) Client-Centered An Ethical Therapy. In M. Bazzano (Ed.). Re-visioning Person Centered Therapy: Theory and practice of a radical paradigm. Routledge, New York, NY 

3. Livingstone, T. (2008). The relevance of a person-centered approach to therapy with transgendered or transsexual clients. Person-centered and Experiential Psychotherapies, 7(2): 135-144.

4. Livingstone, T. (2010). Anti-sectarian, queer, client-centeredness: A re-iteration of respect in therapy. In Lyndsey Moon (Ed.) Counselling Ideologies: Queer challenges to heteronormativity. Ashgate Publishing Limited, Surrey, UK

5. Lev, A.I. (2004) Transgender emergence: Therapeutic guidelines for working with gender-variant people and their families. Haworth Clinical Practice Press, Binghamton, NY

6. Rachlin, K. (2002). Transgender individuals' experiences of psychotherapy. International journal of Transgenderism, 6(1).

7. Raj, R. (2002). Towards a trans-positive therapeutic model: Developing clinical sensitivity and cultural competence in the effective support of transsexual and transgendered clients. The  International Journal of Transgenderism, 6(2). 

8. Sheerin, J. M. (2009). Transgender individuals' experiences in therapy and perception of the treatment experience. Theses, Dissertations, and Projects. 1144. Retrieved from: https://scholarworks.smith.edu/theses/1144