Therapeutic work with gender diversity: analysis of cisgender psychotherapists’ countertransferential reactions with transgender and non-binary patients

Aim: Several studies evidence that transgender and non-binary patients may elicit strong countertransferential reactions in cisgender psychotherapists. Additionally, the literature has highlighted difficulties regarding alliances and trust in the therapeutic relationship with these patients. The present study aims to explore the countertransferential reactions of psychotherapists with different theoretical orientations and backgrounds, with transgender and non-binary patients. Specifically, the study explores the subjective experiences of clinicians during psychotherapy, their attitudes, and their knowledge regarding gender incongruence (GI). Methods: 20 psychotherapists with psychodynamic, cognitive, and systemic orientations were recruited. A semi-structured interview created ad hoc for this study was used and a Consensual Qualitative Analysis (CQR) was applied to the transcripts. The Therapist Response Questionnaire (TRQ) and the Patient Response Questionnaire (PRQ) were filled in by the therapists. Results: Different themes using the CQR emerged: 1) Specific countertransferential reactions of psychotherapists; 2) Setting-related aspects; 3) Personal and professional reflections of clinicians matured during psychotherapy; 4) Psychotherapists’ knowledge regarding gender identity and GI. The TRQ evidenced positive, disorganized, or over-protective countertransferential patterns. The PRQ highlighted anxious/preoccupied behavioral patterns, positive/working alliance, and avoidant/dismissing attachment. Discussion: Very strong and poorly processed countertransferential reactions emerged both among psychotherapists who reported feeling insufficiently trained on the topic of GI and also in those who reported having an adequate level of expertise. Therefore, it is key to promote knowledge and training on GI among therapists, as well as encourage recognition of countertransference reactions to improve clinical practice with these patients.