Building awareness of minority stressors and transgender affirmative therapy: Testing two approaches to psychotherapy with transgender and nonbinary clients

Psychology has a long, fraught history regarding research, psychotherapy, and support for transgender and nonbinary clients: Some of the field’s first written accounts pathologizing transgender identity date from the early 1900s. Since then, the field of psychology has consistently pathologized transgender and nonbinary people. Only in the past 2 decades have scholars begun to discuss how therapy can be affirming and healing for transgender and nonbinary clients, who continue to report difficulty building rapport with their therapists because of microaggressions and discrimination in the therapeutic process. Scholars and activists have been calling for research to address the influence that oppression has on transgender and nonbinary people’s experiences in therapy and to document the effectiveness of the therapeutic process.

In the first published accountopens in new window of a randomized controlled psychotherapy trial with transgender and nonbinary clients in the United States, researchers Stephanie L. Budge, Morgan T. Sinnard, and William T. Hoyt discuss a pilot study that they conducted on two different psychotherapy treatments for transgender and nonbinary clients: transgender affirmative psychotherapy (TA) and building awareness of minority stressors (BAMS) + TA. Their main goal in this study was to determine the feasibility and acceptability of conducting a randomized controlled trial testing these two treatments, and a secondary goal was to explore therapeutic outcomes from each treatment.

Budge and colleagues concluded that the trial was both feasible and acceptable. For example, enrollment was closed after only 1.5 weeks, given the strong interest in participating in the study. Further, only one client dropped out after five sessions because of a scheduling conflict. Although the authors noted that there were some challenges with recruiting therapists for the 12-session study, clients in both conditions attended almost every available session; clients in the BAMS + TA group were more likely to attend all 12 sessions. Regarding acceptability, 100% of clients reported that they had a positive experience in the study, and 100% of clients indicated that they would enroll in the study again if the opportunity arose.

In addition, clients in both psychotherapy conditions reported clinically significant levels of improvement in their psychological distress. When it came to targeted measures that focused on minority stress, the clients in the BAMS + TA group reported a reduction in internalized transnegativity and fewer nonaffirmation experiences. In addition, working alliance scores were generally very high, and higher working alliance scores were associated with significant reductions in psychological distress.

Budge and colleagues caution that this pilot trial had a small sample size (N = 19) and that conclusions from this study should be replicated and extended with additional research that includes larger sample sizes and asks more nuanced questions about the process of psychotherapy. For example, clients in the BAMS + TA condition received psychoeducation about the concept of minority stress prior to the start of psychotherapy, and clients were asked to identify up to three minority stress events they had experienced over the week prior to each session to prompt discussions about minority stress in session. Clients indicated that they did not like to report on the three minority stress events and that they would have preferred to discuss their goals, regardless of the focus on minority stress in session. On the basis of feedback gathered from this study, Budge and her colleagues in the Trans CARE Collaborative are starting an open trial in January 2022 that will have a much larger sample and will focus on trans, Two Spirit, and nonbinary clients of color who will be paired with trans, Two Spirit, and nonbinary therapists of color trained in specific modalities that address the role of oppression in psychotherapy.

Note: This article is in the Clinical Psychology topic area. View more articles in the Clinical Psychology topic area.

Budge, S. L., Sinnard, M. T., & Hoyt, W. T. (2021). Longitudinal effects of psychotherapy with transgender and nonbinary clients: A randomized controlled pilot trial. Psychotherapy, 58(1), 1–11. https://doi.org/10.1037/pst0000310opens in new window

Stephanie L. Budge (she/her) is an associate professor in the Department of Counseling Psychology and the director of the Advancing Health Equity and Diversity program in the Collaborative Center for Health Equity at the University of Wisconsin–Madison. She is the founding member of the Trans CARE Collaborative. Her research focuses on improving medical and psychotherapy treatments and access to care for Two Spirit, transgender, and nonbinary clients.

Morgan T. Sinnard (she/her) is a postdoctoral fellow in rehabilitation psychology at the Tibor Rubin VA Medical Center in Long Beach, California. She earned a PhD in counseling psychology at the University of Wisconsin–Madison. Her research focuses on systemic oppression and health.

William T. Hoyt (he/him) is a professor in the Department of Counseling Psychology at the University of Wisconsin–Madison. He studies counseling processes and outcomes, and his interest in research methodology extends to measurement and data analysis techniques.