ACT for Gender Identity

The Comprehensive Guide

Alex Stitt

• Publisher: Jessica Kingsley Publishers
• Year: 2020
• Print ISBN: 9781785927997
• eBook ISBN: 9781784508128
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Increasingly adopted by therapists and mental health professionals, Acceptance and Commitment Therapy (ACT) helps clients to cope with social, emotional and mental health issues by using the six core ACT processes: Acceptance, Cognitive Defusion, Being Present, the Self as Context, Values and Committed Action.

This is the go-to-guide for evidence-based ACT techniques to be used by professionals to help their transgender, genderqueer, genderfluid, third gender and agender clients. It provides the tools to help these clients develop emotional processing skills they can implement throughout their life, from coping with mental health issues and substance abuse, to navigating prejudice and social pressure, to building a career and developing a family.

1

Introduction

Storm Cloud Butterflies

To be fierce is to be proud of yourself in the face of adversity.

To be fabulous is to inspire others by being exactly who you are.

Accepting our gender in a world of prejudice, heterosexism, cissexism, and transphobia often feels like a butterfly trying to glide through a rain storm. Having come so far and transformed so much, navigating life’s maelstrom feels overwhelming. Despair is common, and loneliness doubly so. Outrage is understandable, and the torrential shame is blown on gusts of fear and bias.

Take heart that the world is changing. The 2016 census performed by UCLA’s prestigious Williams Institute found that, in less than a decade, the number of transgender Americans had doubled from 0.3 percent to 0.6 percent (Flores et al., 2016c). That’s approximately 1.4 million remarkable human beings. Of course, 700,000 transgender individuals didn’t suddenly materialize out of thin air. We were always here, but after decades of advocacy, social education, hard-won political battles, fallen friends, gained allies, and massive changes in the field of mental health, the chrysalis finally cracked. The youth of America are finding more liberty to express themselves, while those who have spent their lives hidden are beginning to emerge with both community support and even community celebration.

The change from gender identity disorder to gender dysphoria in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) 5th edition (2013) attested to the realization that the brunt of mental health issues facing transgender individuals—from post-traumatic stress disorder (PTSD) to anxiety, self-harm, substance abuse, eating disorders, and suicidal ideation—do not derive from having a transgender identity. A healthy community, embodied by unconditional acceptance, cultivates healthy identity constructs. Quelle surprise. On the other hand, a society comprised of deleterious homogeny, where uniqueness is quashed and children are made to feel like pariahs, has only one outcome: a hateful downpour.

Following suit, the World Health Organization (WHO) depathologized gender variance in their 2018 revision of the International Classification of Diseases (ICD-11). Removing gender variance as a disorder, the ICD-11 still includes gender incongruence as a diagnosis, as therapy is still beneficial to individuals seeking self-actualization, and many nations around the world require a diagnosis in order to provide therapeutic or medical assistance.

We know that storms do not subside quickly, and that the dangers facing trans populations remain all too real. The extensive 2011 National Transgender Discrimination Survey found that 46 percent of trans men and 42 percent of trans women attempt suicide, with increased risks amongst individuals who are differently abled, who have mental health conditions, or who are HIV positive (Grant et al., 2011; Haas, Rodgers, and Herman, 2014). Echoing this dark fact, the 2015 US Transgender Survey, produced by the National Center for Transgender Equality, found that 40 percent of trans individuals had attempted suicide in their lifetime (James et al., 2016). This same survey underlined how 47 percent of the trans population had been sexually assaulted in their lifetime, with 46 percent of respondents being verbally harassed, and 9 percent being physically assaulted in the last year alone.

So how can you, as a mental health practitioner, possibly aid a population so targeted by prejudice, misconception, and hateful propaganda? What can you provide when the courageous advocate—who’s been fighting the good fight since they were old enough to realize they were different—breaks down because they feel so utterly overcome? How can you aid gender variant people fatigued by the armor they’ve worn for so long? Or help the genderqueer teen exhausted from correcting pronouns? Or the trans man angry at their family’s disapproval? Or the genderfluid person’s shapeshifting anxiety?

While cognitive behavioral therapy (CBT) and person-centered therapy (PCT) have certainly helped clients manage an array of gender-related issues to various degrees of success, many mental health practitioners working with transgender clients often pine for something more. Ideally a shift in society or a calm in the storm would be nice, yet when this is not available in the immediate future the need for a specialized therapeutic modality becomes clear.

Gender affirmative therapy requires practitioners to not only take a deep look at themselves and their own conceptualization of gender, but to adopt values that empower the full range of gender identity, expression, and experience (Ali, 2014; Ansara, 2010; Carroll, Gilroy, and Ryan, 2002; Livingstone, 2010; Raj, 2002). A trans-positive therapist needs to take into account the role of systematic oppression and social alienation in order to conceptualize autoplastic and alloplastic treatment plans. By affirming the client’s autonomy, you can shed the expectations and role impositions of gender binary from the therapeutic relationship, yet this is only possible if you monitor the role gender plays in both transference and countertransference. This may require you to familiarize yourself, not merely with the new, ever growing terms applied to gender identity and gender pronouns, but with the field of queer theory (Frank and Cannon, 2010). Evolving from post-structural feminism, queer theory highlights how gender is a core component to identity, without ascribing to inflexible norms and expectations (Gamson, 2000). When you no longer presume there is a binary of black and white, you are free to see a rainbow continuum.

Gender variance, in this text, describes the complete array of possible gender identities, as not all outside the binary identify as transgender, for a myriad of personal and cultural reasons. A wider umbrella, gender variance encompasses a range of gender constructs including, but not limited to, post-op, pre-op, and non-op male-to-female (MTF) and female-to-male (FTM) people, trans men and trans women who do not seek complete transition, as well as genderqueer, genderfluid, agender and third gender individuals (Andre and Guitierrez, 2010; Ettner, 1999; Kusalik 2010; Luengsuraswat, 2010; Mallon, 2009). Gender variance can also include binary and nonbinary cisgender people whose gender expression exceeds their cultural gender norms, which in turn can make them targets for abuse (Devor, 1989; Lucal, 1999). These include transvestites, drag artists, and queer identities that identify with their anatomic sex while bending, blurring, or breaking their gender role.

With such a diverse array of people, many therapists strive to be trans positive by increasing their awareness of psychosocial issues facing the gender variant demographic and by continuing their development in multicultural competency. Yet literature providing an actual therapeutic modality is scarce. In other words, while therapists may be able to conceptualize the issues at hand, and validate the struggle, they’re not always certain how to help. In recent years, the popularity of Acceptance and Commitment Therapy (ACT) has steadily been on the rise, due in part to its wide applicability, and how ACT combines elements of Skinnerian contextualism with mindfulness practices akin to many Eastern philosophies including Zen Buddhism. ACT is unique in its focus, as it encourages us to accept our complete emotional experience without the pitfalls of avoidance or maladaptive coping mechanisms. Subsequently, ACT is an ideal mode of therapy for developing and affirming gender identity and emotional resilience.

Steven Hayes, the founder of ACT and celebrated author of Get out of Your Mind and into Your Life: The New Acceptance and Commitment Therapy (Hayes and Smith, 2005), presents six ACT precepts easily adapted to gender affirmative therapy:

1. Acceptance: Relinquishing avoidance strategies to accept our emotions allows gender variant individuals to come to terms with the full experience of who we are. This is a vital step as many of us endure closeted or compartmentalized periods of our life as a maladaptive survival mechanism. Furthermore, attempts to ignore or power through macro-, meso-, and microaggressions can have a detrimental effect on both physical and mental health (Roland and Burlew, 2017).

2. Cognitive defusion: Understanding cognitive–emotional fusion (being at the mercy of our thoughts and feelings) and cognitive–emotional defusion (being able to take a step back to allow for calm objectivity) allows us to move from emotional reactivity to living a proactive, self-actualized life. Shifting our relationship with our thoughts to observe cognitions and emotions without judgment is a key step when coming to terms with both who we are and how we feel.

3. Being present: Implementing mindfulness in the here and now helps to cultivate direct contact with our senses and our environment. In doing so, past trauma and intrusive thoughts are able to enter the mind and dissipate via meditative practice.

4. Self-as-context: Utilizing perspective-taking and metaphors, ACT develops an understanding of how language forms our locus of perspective (here vs. there, now vs. then, I vs. you). By increasing our mental flexibility and recognizing how we naturally develop a multifaceted identity—inclusive but not limited to our gender—we are able to develop emotional and psychosocial adaptability.

5. Values: Developing awareness around our values in order to make healthy, proactive life choices helps us nurture our self-knowledge and personal pride in order to combat internalized homophobia and transphobia. While validating gender identity is integral, validating our core value construct is both clarifying and empowering.

6. Committed action: Making active steps to embody our value constructs in order to maintain a healthy identity has always been the most difficult and ultimately most rewarding step of the coming-out and self-affirmation process. This stage of ACT is most akin to other behavioral modalities, as it requires measurable, concrete steps to shifting behavior.

How we cope with the hardships of the outside world is, was, and will always be the source of both our pain and our victory, our despair and our passion. Indeed, with the client on the couch, it becomes clear that both the storm and that courageous butterfly exist together within them, with every original hope and internalized fear. Uniquely, ACT provides a route through this inner storm, useful to any practitioner striving to help gender variant clients come to terms with both identity and emotional acceptance.

As a nonbinary person and a licensed mental health professional, I must own my bias, and explain the grammatical voice of this text. Like so many outside of the statistical bell curve, I have been the misunderstood child, and the distraught teen, and the fatigued adult sat across from bewildered therapists who didn’t know what to do with me. Yet like so many therapists, I also endorse the restorative power of relational connection, and have learned a great deal of humility from my turn in the clinician’s chair. Empathizing with both, I hope to challenge how we think about the therapeutic relationship by reconstructing the conversation, yet to do so I had to make a very personal linguistic choice. I am a person before an occupation, so instead of writing as a clinician for clinicians, I nest my professional insight within my experience as a gender minority, aligning my voice with those of the clients.

To conceptualize the sheer diversity of gender, we will periodically meander through culturally contextual case vignettes, using they, them, and their unless pronouns are specified. Yet when authors sit the reader apart from the subject for too long, relatability is often sacrificed for objectivity. In research literature, transgender and nonbinary identities are often treated as a peculiar novelty, regarding those people and their experience over there. This language of distinction inadvertently creates a false divide from that of the reader, contributing to unnecessary frames of opposition. For this reason, much of this book is written in the first-person plural, so that we can understand each other, together.

Since this is a clinical guide, you will be distinguished only when we need to address your role as the clinician, or to focus your attention on your personal experience. Admittedly, your therapeutic role does set you apart— not because of your gender— but because you are the second half of our wonderful conversation. As ACT encourages us to hold ideas loosely by challenging rigid constructs and absolute thinking, we may shake things up a bit, allowing us to be as radically different as we are universally similar. Side by side, we will complete exercises together, and from time to time we’ll let you know what kind of questions may be helpful to ask, or what you may need to be mindful of in such delicate situations. This inclusive writing style may be natural for some and awkward for others, as clinicians are rarely instructed by clients.

Language most certainly influences our perception, but it does not determine our existence, it only describes it. Too often, gender development is conceptualized on a fixed track, from boys to men or girls to women, framing our language in rigid terms of normalcy and homogeny (Nagoshi and Brzuzy, 2010). Yet our experiences are as diverse as our identities, and we all explore and re-explore gender at our own pace. Exceeding physical presentation and personal pronouns, gender impacts our entire construct of self—personally, intellectually, socially, academically, occupationally, and spiritually. Who are we? What is our relationship with our body? How do we move through this world? How do we express ourselves? No matter the answer, the question is relatable to all, marking all responses as meaningful, and therefore worthy of compassion and empathy.

Gender identity actualization is not a solely transgender experience, yet for cisgender individuals (male men and female women) who may have taken their gender identity for granted, it may be difficult to examine. So, let us begin here with a tentative, delicate feeling as hopeful as it is nervous. All too often, we enter session hoping to banish anxiety once and for all! This, ACT observes, is the agenda of emotional control in action. Ironic process dictates that the more we try to duck and dodge the rain, the more we seem to get wet, which is to say, the more we try to get rid of our emotions, the more emotions are brought to the forefront of our attention (Wegner, 1994; Wegner et al., 1987; Wenzlaff and Wegner, 2000). Unable to eradicate our feelings, we may begin to loathe them, reject them, even fear them, leading to depression and anxiety. At this point, we often experience two gut responses. The first is a knot, signaling that we’re in over our head—that the storm has become too great. The second is a prelude to this knot, a fluttering in our stomach best described as trepidatious butterflies.

Though beautiful and transformational, butterflies are so often associated with anxiety, as the precursor of a panic attack or something to avoid. But what if those very same butterflies were actually our fragile courage? What if those butterflies were our call to action? Evidence that we have taken one step past our comfort zone? One step closer to authenticity? If you have ever felt those vulnerable butterflies in your tummy at the thought of disclosing some personal truth—even if only for an instant— then you might understand some small glimmer of what it’s like ...

Table of contents

• Cover
• Title Page
• Contents
• 1. Introduction: Storm Cloud Butterflies
• 2. Gender Affirmative ACT
• 3. Awareness
• 4. Acceptance
• 5. Actualization
• 6. Adaptation
• 7. Affirmation
• Epilogue: Of Moths and Meaning
• References
• Subject Index
• Author Index
• Join Our Mailing List
• Copyright
• Of Related Interest