There currently seems to be much discussion about affirmative vs explorative therapy with trans clients. As though they are binary opposite ways of working and we can’t do both. The aim of this blog is to de-bunk some of the myths of this unhelpful binary as I see it. 

Working affirmatively

I’ve been troubled by hearing therapists referring to affirmative therapy for trans clients as ‘dangerous’. And therefore deciding to not work affirmatively. I’d like to pose a different question; why would you not work affirmatively with any aspect of a client’s identity? My understanding of the word affirmative is about working in a way that upholds that no one identity or aspect of identity is considered more desirable than another. So, in this case, no one gender identity is considered more or less desirable than another. 

Exploration

Alongside the discussions around ‘affirmative therapy*; there seems to be a conversation about what ‘exploratory therapy’* involves. An assumption that it is always pathologising and as though there is somehow a binary of affirmative OR exploratory. That on one ‘side’ affirmative equals good and exploratory equals bad vs the ‘other side’ where exploration equals good and affirmation equals bad. I disagree.

Using the example of long waiting times for NHS gender clinics (see below). A trans client will of course be upset and frustrated at the long wait. We can be affirmative in this as it IS frustrating, it IS a long wait! We can also explore what else the waiting and uncertainty might bring up for this client. What family dynamics might be evoked? What does waiting feel like? How can they support themselves during the long wait? These are all things that can be safely explored with open curiosity. What is therapy if it’s not an exploration, whatever modality we use? What is life if it’s not an exploration of who we are, how we experience the world around us?

The sort of exploration that would be unhelpful and potentially damaging is trying to find ‘reasons’ behind why a person is trans. We don’t look for reasons why someone is cis-gender. We simply work affirmatively with them. So we need to carry this across to all genders, and all aspects of identity. I think it’s really important that we are clear about what terms we are using and the intent behind them. This way we can engage in furthering our understanding of ourselves and others. 

Unprocessed beliefs in the therapist

So, coming back to the question around affirmative vs explorative therapy, why would it be dangerous to work affirmatively? Who for? What feels dangerous to the therapist about it and can this be explored in supervision and personal therapy? (Rather than negatively impacting the client with their own unprocessed material.)

“You wouldn’t let your client step in front of a bus so why would you work affirmatively with trans clients”. These kind of comments are unhelpful on so many levels. Making these kinds of parallels are transphobic at their core. To link with suicidal ideation makes a suggestion that being trans is the equivalent to taking one’s own life. And that the therapist is somehow supporting this. What unprocessed material is going on for the therapist to make this incorrect assumption?

I don’t ‘let’ or ‘not let’ my clients take their own lives. Recognising what is and isn’t within my control is helpful. I work through what that feels like to not have the ‘control’ to keep clients alive. To not do so potentially indicates a lurking saviour complex. Perhaps a topic that deserves a dedicated post, so more on this later. 

Affirmative vs explorative therapy

Working affirmatively is about working with who the client is, not what actions they take; what they do. It isn’t our job to encourage or discourage a client to take a specific action. We wouldn’t/shouldn’t be telling our clients to/not to leave a relationship, change a job, have a tattoo etc. So why would we be telling our clients what gender they are or are not?

Is there any other aspect of identity where it would be considered OK to attempt to prevent the client from expressing themselves? E.g. a trans client who is also black, Muslim, disabled and working class. Why would we work affirmatively with all these other aspects but not with their gender identity? If we are not working affirmatively with all these other aspects, why not? 

Transition process

For any therapists or supervisors who are not aware, it is not, and likely will never be, their role to diagnose, to prescribe, to refer for surgery for trans clients. In the same way that we would not for any other client group. There are specifically qualified professionals for working with gender dysphoria for trans and trans questioning clients.

In terms of medication and surgical interventions via the NHS, trans clients will likely be on a 5 to 8 year waiting list before first intervention is offered. This is owing to the number of people on the waiting lists and the small number of trained care staff. It is possible, for those who can finance it, to be seen more quickly privately. However, there is usually a 6 to 9 month wait for assessment privately. What this means in reality, in the UK, is that no one has access to medical or surgical intentions quickly. There is plenty of time for reflection along the way before the client makes decisions about how to proceed and they can stop or pause the process at any point. 

Our role as therapists is to provide psychological support in whatever way is needed. The client may need help with navigating systemic transphobia, family/work responses to their identity. Or they may bring something completely unrelated to their identity. So we can work both affirmatively and exploratively without directing, shaming or pathologising the client. 

Working affirmatively and exploratively

So, please can we move away from ‘debating’ identities and simply respect and respond to the client in our care. Do you find you have a strong reaction to terms like working affirmatively or exploratively? Please spend some time in personal reflection about what fear or anxiety might be stirred in you. And of course refer the client on to someone who is competent at working both affirmatively and exploratively whilst you work through whatever difficulties you have. 

*I am using the word affirmative to describe working in a way that upholds that no one identity or aspect of identity is considered more desirable than another. I am using the word exploratory to describe working in a way that explores how a client feels about what they are bringing, not exploring how/why/if a client knows they are trans and/or how this aspect of identity can be changed