Molly, an experienced therapist and gender realist, recently found herself in a ten minute introductory conversation that felt less like a consultation and more like an ideological audition. The potential client has arrived to discuss ongoing therapy, but emerges with a demand for a pre-emptive alliance in response to the therapist confessing that she is a gender realist. She made it clear that she has many trans friends and that, in her view, it was simply awful to feel one is in the wrong body. She then issued a challenge that many modern therapists now dread: she asserted Molly was “not like her” and insisted on knowing if they shared the same views on gender before therapy could even begin.
Molly’s response to this included an explanation that she is a member of Thoughtful Therapists a group who believe that sex is binary and immutable, she emerged feeling “discombobulated” she mentions “a nail in the coffin” when the client declared the awfulness of being in the wrong body. The relationship had fractured and specifically she is very anxious – a risk of being REPORTED as a transphobe.
There are many therapists in the group and they are all offering advice, such as putting your gender realist credentials on your CV. What I also find interesting is the rescue response of some members, taking on the role of “counsellor”- you did well, you kept your head, it went fine. It didn’t go fine. The therapist’s emotions are not to be soothed away, there is something very important to be learned.
I find myself reflecting: What is really going on, what is the solution and what about all this belongs to Molly?
It isn’t uncommon for a client to “contract” for a specific reality before the therapy has even begun. What has happened here is a mini psychodrama. In clinical terms, the client is asking for a Pre-emptive Alliance based on ideological alignment rather than therapeutic trust. When a client says they need you to “share their views” because of their social circle, they are effectively asking you to join their “silo.” For the therapist, this is the moment to be “robust, fearless and professionally aware”. If the therapist doesn’t know how to do this several things are happening.
THE SECRET MESSAGE IN THE CLIENT’S WORDS
Let’s revisit what the client actually did. She created a hidden act of social aggression, by saying “you are not like me” implying that she has a high moral ground that the therapist appears to lack and is therefore not to be trusted. It is a subtle form of bullying, and a drama triangle is created, where the client becomes the aggressor and Molly is the victim. What is interesting is that “inside her head” even if she is not showing it, Molly has accepted the role of victim because her emotions have been engaged. What the client is doing is an act of projective identification: she is “shoving” a feeling of wrongness /unkindness into Molly, “I will make you feel as uncomfortable, ‘outside’ and unkind as I feel.”
The client also mentions that she has many trans friends, adding that it must be dreadful to be in the wrong body – inviting the therapist to agree, to tell a lie by exclusion (the therapist believes that the body is just as it should be) or to disagree and confirm that she is a bad person. The therapist is being told to affirm a biological impossibility (a body being “wrong”) on behalf of people who aren’t even in the room. Well, they are in the room now, using the client as a proxy for all the gender-confused people whose experience of being in the wrong body is “awful”. Molly’s hesitation is noted because the initial contract was not intended as a debate about politics, and control of the narrative is lost.
This is what Molly experiences as a nail in the coffin. It is a powerful metaphor. The nail could be seen as the Performative Kindness being demanded of Molly, resulting in surrender of control to try and maintain engagement with the client and please her sensibilities. The coffin is collapse of the therapeutic space in which Molly is now buried. The drama triangle is firmly anchored – the therapist is, in this moment, disempowered; if she agrees with the client she is a liar to her own beliefs; if she does not she is a persecutor in the client’s eyes. I suspect that Molly is now experiencing a strong personal countertransference, focusing on her own emotional survival and professional survival under the client’s subtle personal attacks.
A 4th party therefore enters the room, the Professional Association, and the anticipated feelings that association will have toward her if the client accuses Molly of being transphobic. Molly is now experiencing institutional countertransference. When a therapist is “alarmed” by a statement of difference, they have lost their Professional Agency. They are no longer listening to the client; they are listening to the imagined voice of a disciplinary panel. Hence Molly starts talking to herself about her assumptions where “wrong-speak” is treated as a high-level offence. Being different from a client is not a reportable offence but being hostile to the MoU may be.
Molly may think that she has scraped out of the interaction with dignity, but she has lacked the right words to deal with the situation, possibly because was side-lined by the unexpected direction of the conversation. Her discombobulation afterwards is a powerful message that something needs attention. We need to attend, not try to soothe Molly’s feelings away.
THE THERAPIST ISSUES
We may ask ourselves what causes Molly to be caught in a drama triangle in the first place – and not to recognise it when it occurs. We become therapists because we want to help, we are nice people and often driven to please or placate. Our personal traumas that we believe we have managed in personal therapy have been triggered.
If we can recognise the immediate descent into the victim position – where the client infers we are not kind enough, we must take ourselves out of the drama triangle at the speed of light. To explain one’s position on gender or, that one is a member of Thoughtful Therapists, is defensive and makes things worse. To anchor our status as a coach, not a victim, a far better response might be:
You are right, we are different people. Might this be part of the issue that brought you here, the difficulty relating to people who may not share all your views in life?
It is true that I am not you and have not lived your life. How might my being ‘different’ actually serve us here, perhaps by offering a perspective that isn’t already inside your own head?”
I hear a concern that if I don’t share your specific views, I won’t be able to truly hear you or hold your distress. Does it feel as though my ‘difference’ is a barrier to us working together?”
I am curious about what has led you to say this to me.
The other statement for which a prepared answer is needed is the attempt to engage the therapist in performative kindness toward a group who are not present to speak for themselves “it must be awful to be in the wrong body” – setting Molly in a loaded empathy trap. The client tries to pull Molly into a rescuer role for a very variable group of people.
I find myself resisting this pull to empathy because I have so much experience of wrong embodiment, among people with anorexia, or with obesity, or with other forms of dysmorphia. BUT it would be defensive for me to call on this experience and put myself in the position of persecutor (using my professional status to belittle the client). I will say instead:
You feel very strongly that the experience of trans people is one of profound suffering. Is this so? How does this affect you?
How do you personally deal with this sense of awfulness, is it something you would like to explore in therapy?
JUDGEMENT FREE REFLECTION
Bottom Line: in this interaction, the therapist has reacted to statements rather than sit in the place of evaluating them and being curious about what has led to them. This asks what anxiety in the therapist has been triggered. I have come to think that the solution is for no therapist to LABEL ourselves as gender realist or make a political statement of allegiance or membership of any activist group (including of therapists). Activism of any kind in a therapist may not be helpful.
We need advance preparation for what to do when these conversions of belief and ideology show up. We also need to be professionally secure, and if we are not because of where we work, this needs to be addressed.
FEAR OF SANCTION:
Where does this come from, is it realistic? If realistic what is the evidence? BE CLEAR – a professional body can try to initiate a conduct hearing, they have to prove that you have breached your duty of care. Molly is entitled to have gender realist beliefs and must treat patients under the Montgomery Ruling 2015 to avoid harm at all costs. That is a legal imperative; the MoU is just a guidance. BE CLEAR – A professional authority cannot sanction you for focusing on your Duty Of Care under Montgomery. See https://eating-disorders.org.uk/the-mou-conversion-practices-and-the-law/
CONCLUSION : This was not a scenario that requires us to agree that the client was difficult or that the therapist was the only sane one in the room. That may be true. But a nuanced learning is needed. I hope that this short case evaluation has helped.