The development of an observational coding scheme to assess transgender and nonbinary clients’ reported minority stress experiences

Abstract

Trans and nonbinary individuals experience high rates of identity-based stigma and stress (minority stress) in U.S. society. Despite research empirically linking minority stress with adverse mental health outcomes, the extent to which minority stress experiences are discussed in psychotherapy and how therapists respond is unknown. The primary aim of the present study was to develop and test an observational coding scheme, the Minority Stress Experiences and Interactions (MSEI) scheme. With this scheme, observational data from psychotherapy sessions with 19 TNB adult psychotherapy client participants were coded to provide pilot data for the initial development of the MSEI coding scheme. Nineteen clients’ entire 50 minute psychotherapy sessions were coded over three phases of psychotherapy: beginning (session 1), middle (session 2), and end (session 10/11). Results indicate that the MSEI scheme was reliable for most codes. Codes revealed that all (N = 19; 100%) clients in the study reported at least one minority stress event (MSE) over the course of the three sessions, with the mean number of MSEs being 7 per client. The most frequent proximal stressor reported by clients was related to internalized stigma and the most frequent distal stressor reported by clients was prejudice. Two clients’ clinical exchanges with their therapists centered on MSEs are highlighted to demonstrate the nuance of how MSEs are discussed in session, specifically regarding multiple minority identities. Implications for the current study include the need for therapist training regarding minority stress interventions and attention to power and oppression within sessions.

Research has demonstrated that transgender and nonbinary people (TNB) experience higher levels of mental health concerns and psychological distress than their cisgender peers, including anxiety, depression, and suicide risk (Bockting et al., 2013; Budge, et al., 2013; Tebbe & Moradi, 2016). Scholars have attributed these disparities to experiences of minority stress (Hendricks & Testa, 2012; Lefevor et al. 2019; Testa et al., 2017). This body of research typically focuses on quantitative associations between the experience of minority stressors and specific mental health concerns (e.g., depression, anxiety), with research rarely addressing more nuanced and complex interpersonal interactions related to minority stress. As well, despite an ever-growing body of literature that provides an explanation for mental health disparities for TNB populations, very few studies focus on interventions that address minority stress (see Austin et al., 2018) and, to date, only one study is a psychotherapy intervention (Budge et al., 2020). Despite consistent calls from researchers and scholars to attend to minority stress experiences in therapy (e.g., Lefevor et al., 2019; Westmacott & Edmondstone, 2020), the lack of empirical research on minority stress interventions maintains a large gap in the literature regarding the extent to which minority stressors are discussed in psychotherapy, what kinds of minority stressors are discussed, and the types of interactions that occur with therapists and clients around these topics. The purpose of the current study was to create a coding scheme and to code psychotherapy sessions with TNB clients to address this gap in knowledge.

Minority Stress as Risk Factors for Mental Health Concerns

Brooks (1981) and Meyer (1995; 2003) theorized the minority stress model and originally applied the model to lesbian, gay, and bisexual (LGB) individuals. Minority stress theory describes how LGB-related stigma, prejudice, and discrimination contributes to chronically stressful environments, which results in adverse mental health outcomes. Meyer (2003) categorized minority stress experiences as: a) distal (external experiences such as discrimination and harassment), b) proximal (internal experiences such as internalized transphobia), and c) the expectations that distal events will occur. Recent literature has extended the model to TNB individuals, theorizing and finding that TNB-specific distal and proximal stressors minority stress contribute to mental health concerns (Bockting et al., 2013; Hendricks & Testa, 2012). Moreover, scholars have suggested that TNB people may experience even greater levels of minority stress than LGB people, and that minority stress experiences may differ among TNB people at specific critical periods (e.g., medical transition) in developmental processes (Hendricks & Testa, 2012).

Building on conceptual and theoretical scholarship, empirical research investigating the theorized suppositions of the minority stress model for understanding high rates of adverse mental health concerns among TNB people have largely been supported. In one of the first studies to demonstrate this application, Bockting and colleagues (2013) confirmed that both felt stigma (proximal stressor) and enacted stigma (distal stressor) contributed to mental health issues for trans men and women. In addition, Tebbe and Moradi (2016) found that minority stressors were associated with depression, suicide risk, and substance use in trans individuals. Gender-based victimization has also been identified as a significant contributor to psychological distress in TNB adults (Bariola et al., 2015) as well as adolescents (Hatchel et al., 2018). Despite a greater understanding of how Brooks’ (1981) and Meyer’s (2003) LGB-focused theory is scientifically demonstrated to TNB people (Hendricks & Testa, 2012), the original and expanded theory continues to fall short of TNB people’s experiences. Puckett (2020) provides an analysis of how several components of minority stress have yet to have been captured in previous minority stress theory, including inadequate nuanced understanding of concealment, a lack of focus on misgendering, and not including how other TNB people’s narratives may impact one’s own TNB identity.

To date, research on minority stress for TNB individuals has mainly focused on minority stress experiences that specifically relate to transgender identity and expression. However, scholars have suggested that TNB individuals with multiple marginalized identities may experience unique stressors and face greater rejection (e.g., Balsam et al. 2014) as a result of multiple intersecting forms of identity-based oppression. Interestingly, however, research has not consistently found mental health differences between TNB Black, Indigenous, People of Color (BIPOC) and White people (Cyrus, 2017; Hatchel et al., 2018). One possible explanation centers on study design and how core constructs have been operationalized. Typically, studies have attempted to parse out experiences of stigmatization and marginalization as related to individuals’ specific identities, rather than capturing more nuanced reasons for the stigma. Thus, implications for how well key tenets of minority stress theory hold true for TNB individuals with multiple marginalized identities has not been fully understood.

Intersectionality theory, first coined by Kimberlé Crenshsaw (1989; 1991), and extended by other Black, Indigenous, and POC feminist scholars and activists (e.g., Hill Collins, 2000) is another theoretical framework that may help to theoretically and empirically explicate within-group variability regarding experiences of identity-based stigma and oppression. Intersectionality theory was developed to describe how Black cisgender women’s experiences of racism and sexism were treated as separate matters in US law; this theory has been extended by additional scholars of Black feminist thought (Hill Collins, 2000). Scholars using an intersectional framework have been critiqued in the field of psychology for the lack of attention to systems of power and oppression and solely focusing on multiple marginalized identities (Moradi & Grzanka, 2017). For the purposes of our present study, we hope to address these gaps by attending to systems of power in each aspect of the study—from who has been involved in the research team, to the development of study design, who our participants were, how we created the coding scheme, who was involved in coding, and how we interpreted our results.

Psychotherapy for TNB Clients

Although minority stress theory (Brooks, 1981; Meyer, 2003) and intersectionality theory (Crenshaw, 1989; Hill Collins, 1991) can be integrated to more effectively understand the complexity of disparities, it is also important to understand how psychotherapy impacts TNB people, and how systems of power, privilege, and oppression shape dynamics between therapists and clients. In a content analysis of the effectiveness of attending to gender identity in psychotherapy, Budge and Moradi (2018) identified only 10 empirical articles related to psychotherapy with TNB clients. From these studies, the authors identified multiple themes, including the importance of a strong therapeutic alliance and transgender affirmative approach in therapy, clients’ anxiety and fears around talking about gender, and prevalence of negative experiences in therapy (see Mizock & Lundquist; Morris et al., 2020). In one empirical article exploring transgender clients’ experiences of psychotherapy, Applegarth and Nuttall (2016) found that clients view psychotherapy as “fearful” and experience anxiety around discussing their gender identity with therapists. This may be unsurprising considering how many transgender people report negative experiences in therapy. A qualitative study of 10 aging transgender and gender nonconforming clients conducted by Elder (2016) found that all 10 participants described negative therapy experiences in the past, though many acknowledged that therapy services for transgender people have improved over time.

With a growing body of evidence suggesting the high degree of prevalence for TNB clients’ negative experiences in therapy, recent research has sought to identify specific types of negative experiences that TNB clients report. In one notable study of transgender participants’ negative experiences, Mizock and Lundquist (2016) identified common therapist missteps that included education burdening (e.g., clients educating therapists on transgender issues), gender inflation (e.g., overinflation of the importance of gender on the client’s concerns), gender narrowing (e.g., therapists holding limited preconceived notions of gender), gender avoidance (e.g., not exploring gender enough in therapy), gender generalizing (e.g., assuming that the trans community is homogenous), gender repairing (e.g., aiming to “fix” gender identity), gender pathologizing (e.g., viewing gender variance as a mental illness), and gatekeeping (e.g., controlling access to gender-affirming procedures). Through these missteps, therapists may inadvertently exacerbate minority stress experiences for transgender clients in therapy by perpetuating stigma and even contributing to discrimination and reinforcing barriers to accessing other needed health resources and services. A recent study (Morris et al., 2020) underscored these types of negative experiences, describing TNB clients’ reports of therapist microaggressions: lack of respect, lack of competency, over/under emphasizing identity in therapy, and gatekeeping.

While research into what contributes to negative experiences for TNB clients in therapy identifies clear themes, a parallel avenue of research into the positive experiences TNB clients have with their therapists has also recently emerged. TNB participants in one recent study described therapists’ behaviors that lead to an affirmative therapy experience as typically including: the absence of microaggressions, acknowledging cisnormativity, disrupting cisnormativity, and seeing the client’s authentic gender (Anzani et al., 2019). In addition, in a recent randomized controlled psychotherapy trial focused on TNB clients (Budge et al., 2020), transaffirmative therapy training was provided to therapists in both conditions and all clients in the study reported positive experiences overall and demonstrated positive change in outcomes.

Observational Coding in Psychotherapy

Although there is a growing body of research that attends to TNB clients’ experiences of psychotherapy, no published research has focused on observational, in-session processes of TNB clients. Cross-sectional and longitudinal self-report studies are essential to build a body of research that offers a lens into TNB peoples’ experiences. However, self-report has its limitations, including social-desirability bias (wanting to “look good” in the survey) and response-shift bias (when a participant’s frame of reference shifts over the course of the study—especially in interventions studies). Furthermore, participants’ memories can often be skewed or uncertain in retrospective reporting (Rosenman et al., 2011). Observational studies offer researchers with the ability to code interactions in real time and may offer more specific practical applications to clinical work (Yang et al., 2010).

In psychotherapy research, one of the most common forms of observational studies includes an assessment of the therapeutic relationship, with a large body of work specifically focusing on rupture and repairs (e.g., Colli & Lingiardi, 2009; O’Keeffe et al., 2020; Safran et al., 2011). In these studies, several coding schemes were created: the Rupture Resolution Rating (3RS; Eubanks-Carter et al., 2019), the System for Observing Family Therapy Alliances observation (SOFTA-o; Friedlander et al., 2006), and the Collaborative Interactions Scale – revised (CIS; Colli et al., 2019). Psychotherapy observational studies have less commonly focused on identity dynamics and/or oppression, though some studies have coded for interracial dyad processes (e.g., Okun et al., 2017).

Current Study

The main aim of the current study was to create a coding scheme that could capture a wide range of components related to minority stress experiences (MSEs) described by transgender and nonbinary clients to their therapists during psychotherapy sessions. Due to the exploratory nature of this aim, we did not examine formal hypotheses. A second aim was to determine the frequency of MSEs and their type (proximal, distal). Finally, a third aim was to observe therapist-client interactions when MSEs arise in session and to detail typical responses between therapists and clients.

Method

Participants

Clients.

The present study is a secondary analysis of clients randomized to either a trans-affirmative therapy (TA) condition or building awareness of minority stress (BAMS +TA) condition. Clients were recruited through local Wisconsin LGBTQ listservs and flyers were posted in local LGBTQ centers. Clients were able to attend psychotherapy sessions for free and all provided informed written consent. The IRB at the University of Wisconsin-Madison approved the protocol and this study is registered with ClinicalTrials.gov (NCT03369054). Clients were included in the trial if they identified as transgender, nonbinary, or gender nonconforming, were 18 years or older, fluent in English, and were available for weekly psychotherapy during a specific day/time. Clients were excluded if they were currently experiencing psychotic symptoms (assessed via a structured clinical interview) or if they were engaged in ongoing psychotherapy outside of the study. A total of 20 clients enrolled in this pilot trial. One client dropped out of the study at session 5, due to a scheduling conflict; thus, the final participant sample was N = 19. The study was designed for 12 sessions of psychotherapy; the average number of completed sessions was 11 (for N = 19 clients). For more information about the treatment conditions, see the original published article regarding the RCT (Budge et al., 2020). Demographic information of the clients is provided in Table 1.

Table 1.

Participant Demographic Information

Characteristic	N (%)
Age	M = 29.2, SD = 9.8
Race
White	16 (84)
Multiracial	3 (16)
Native American, White	1 (5.3)
Native Hawaiian, White	1 (5.3)
African American, Native American, Latinx, White	1 (5.3)
Gender identity
Non-binary	12 (63.2)
Man	3 (15.8)
Woman	4 (21.1)
Sex Assigned at Birth
Male	5 (26.3)
Female	14 (73.7)
Years since beginning social transition
0–5	12 (63.6)
6–10	5 (26.3)
10–15	1 (5.3)
15–20	1 (5.3)
Have had or desire medical interventions
Yes	15 (78.9)
No	4 (25.2)
Post-secondary education
Some college	6 (31.6)
Associates/technical degree	3 (15.8)
Bachelor’s degree	6 (31.6)
Master’s degree	4 (21.1)
Individual annual income
0–$10,000	3 (15.9)
$10,0010–$20,000	6 (31.6)
$20,0010–$30,000	4 (21.1)
$30,0010–$40,000	4 (21.1)
$40,0010–$50,000	1 (5.3)
Location
Rural	1 (5.3)
Suburban	4 (21.1)

Therapists.

All therapists (n = 4) were trained in transaffirmative therapy (TA) and the two therapists randomized to the BAMS+TA group were trained and supervised using a minority stress framework. The therapists were advanced doctoral students who had completed at least two years of formal therapy training and three out of four therapists had received master’s degrees in counseling prior to entering their doctoral programs. Therapists’ reported that their theoretical orientation was either psychodynamic (n = 2) or person-centered (n = 2).

Study Design and Procedures

The main aim of this study was to create a Minority Stress Experiences and Interactions (MSEI) coding scheme. The purpose of this coding scheme was to develop a systematized way for observers of therapy sessions to reliably code content related to minority stressors in psychotherapy sessions. The coding scheme was created using three phases, drawing from methodology outlined by Bakerman and Quera (2011) and DeVellis (2016). In the first phase, the Trans Counseling, Advocacy, Research, and Education (CARE) team at the University of Wisconsin-Madison discussed the components of minority stress theory (Brooks, 1981; Hendricks & Testa, 2012; Meyer, 2003) and brainstormed what aspects of minority stress should be observed within psychotherapy sessions. The team met for 1.5 hours weekly for 32 weeks to discuss the process of power, privilege, and oppression in psychotherapy study design with TNB people. The first author then created the coding manual based on conversations with the Collaborative. In the second phase, an expert reviewer (faculty member in counseling psychology) provided feedback on the coding manual which informed some initial revisions. In the third phase, two coders piloted the revised coding manual alongside the first author with video recordings for three sessions. Following this, additional revisions to the manual were made in order to increase practicality and usability.

Coding Manual.

The finalized coding manual aimed to identify and capture 10 distinct components: (1) a time stamp for the reported minority stress event to aid code confirmation and to identify key timepoints for transcription; (2) the specific type of minority stressor (proximal or distal stress). Stressors described that were coded as proximal forms of stress included four categories: fear of rejection/harm, rumination on distal stressors, identity concealment, and internalization of stigma (also known as internalized transphobia). Stressors described that were coded as distal forms of stress included three categories: prejudice, harassment, and discrimination. In the coding manual, specific definitions were provided to the coders for each of these categories; (3) whether the therapist or client first mentioned the minority stress event; (4) a short description of the minority stress event. The manual also provided instructions and examples on how to write out descriptions. The next two manual components relied upon which party in the dyad mentioned the minority stressor first. More specifically, (5) if the client was the first to mention the minority stress event, coders indicated if the therapist followed up with a specific intervention related to the event; for the purpose of the coding scheme, intervention was defined as an intentional therapeutic tool used to address, acknowledge, and or deepen the conversation regarding the minority stress event. Next, the coding scheme (6) captured the client’s response to the therapist if it had been the therapist who had first introduced discussion of the minority stress event. In this component, coders also coded the degree to which the client responded to their therapist with four options, which included: changing the subject, minimizing the experience, providing excuses for the person/institution causing the minority stress, or engaging in the intervention with the therapist; (7) how long the interaction lasted as it related to discussion about the specific minority stress event. In the following two components, coders were to (8) code if the client seemed satisfied with the interaction and finally, (9) if coders indicated that the client seemed satisfied, to provide a rationale for why the client appeared to have this response. Finally, (10) coders indicated whether the minority stress event was related to the client’s transgender identity, a different minoritized identity, or to multiple minoritized identities.

Coders.

The two coders were master’s level therapists with expertise working with transgender clients; coders were not therapists in the current study. One coder identifies as a queer, White, trans man and the other coder identifies as an Asian American cisgender woman. The coders engaged in a training as part of the coding process, which included background information on minority stress and processes of video coding. The training included going over the coding manual in depth and discussing multiple scenarios that could arise based on the coding manual and video sessions. As previously described, the first author (a queer, White, cisgender woman who is a licensed psychologist with expertise in working with TNB clients) and coders coded three videos together to answer questions and refine coding processes. Subsequently, all remaining videos were coded by each coder separately, allowing us to estimate inter-rater reliability. The first author was available for consultation throughout the coding processes in case questions arose regarding video sessions and content.

Video Content.

Coders coded entire sessions for Session 1, Session 5, and Session 10/11 for all 19 clients (k = 57 sessions). Sessions were 50 minutes long. Session 1 was chosen due to it being the initial interaction with the therapist and the client and the session during which presenting concerns are first identified. Further, we were interested in the extent to which clients would feel comfortable mentioning minority stress events in their first session or how clients would share this information as part of potential presenting concerns. Session 5 was chosen as a mid-point session in therapy, where presumably enough time would have passed for a bond to have occurred between the therapist and the client. Session 11 was chosen because we wanted the end of therapy to be represented, but we did not want to capture the termination session, as we theorized that the content for termination could be more about the therapist/client relationship and logistics of ending therapy. Some clients did not attend 12 sessions and in those cases, the session that was attended prior to their termination session was coded last.

Results

The overarching aim of this study was to disseminate information regarding the development of the Minority Stress Experiences and Interactions (MSEI) coding scheme. In regards to the coding scheme development process, actual descriptors of how to create a coding scheme for psychotherapy are limited, and to our knowledge, this is the first study of its kind to code for how minority stress is actually discussed in real psychotherapy sessions. Coder inter-rater reliability ranged from 70.42% (for how the client responded to the therapist mention of the minority stress event) to 92.96% (for who mentioned the minority stressor); inter-rater reliability that is 80% or higher is considered “highly reliable” (Lavrakas, 2008). Coders met in person and came to agreement on all items that were not originally agreed upon. Frequency information for all codes are provided in Table 2.

Table 2.

Frequencies of Minority Stress Experiences Reported in Therapy Sessions

	k/n	%
Total clients reporting any MSE	19	100
Number of client MSEs	1–16 (range, M = 7)
Total MSEs for Entire Sample	133	100
MSEs Session 1	55	41.36
MSEs Session 5	44	33.08
MSEs Session 10/11	34	25.56
Proximal MSE
Internalized stigma	25	-
Rumination on distal stressors	23	-
Fear of rejection	17	-
Identity concealment	13	-
Distal MSE
Prejudice	69	-
Discrimination	23	-
Harassment	22	-
Identity Related to MSE
TNB identity	90	67.69
Multiple minority identities	16	12.03
Sexual identity	15	11.28
Disability	7	5.79
Race	4	3.01
Gender (not TNB-related)	1	0.08
Client-Therapist Interaction
Client-initiated MSE	120	90.22
Therapist-initiated MSE	13	1.87
Therapist responded to client’s MSE	90	67.67
Client response to therapist MSE intervention
Engage with therapist intervention	64	-
Change the subject	17	-
Minimize the experience	15	-
Provide a rationale for the person/institution involved with the stressor	4	-

Note: MSE = minority stress event; TNB = transgender/nonbinary; dashes indicate when more than one category could be coded at once, therefore percentages are not reported

Frequency of Minority Stress Events

Throughout the three sessions, a total of 133 Minority Stress Events (MSEs) were coded. All 19 participants described at least one MSE over the course of the three coded sessions, with the number of MSEs ranging from 1–16 (M = 7, Mdn = 6, SD =3.92). MSEs decreased in frequency over time, with clients reporting the most MSEs in Session 1 (k = 55; 41.36%), the next highest frequency of MSEs in Session 5 (k = 44; 33.08%), and the lowest frequency of MSEs in Session 11 (k = 34; 25.56%). Notably, there was no difference between the frequency of MSEs and the treatment condition (BAMS+TA M = 7.33; SD = 4.03; TA M = 6.70, SD = 4.22); t(17) = .33, p = .74.

Regarding type of MSE, for proximal stressors, the most common MSE discussed in sessions was internalized stigma (k = 25), followed by rumination on distal stressors (k = 23), fear of rejection (k = 17), and identity concealment (k = 13). The most common distal stressor that emerged in sessions was prejudice (k = 69), followed by discrimination (k = 23) and harassment (k = 22); percentages are not reported above due to the possibility of more than one stressor being rated for each exchange. Participants identified that the vast majority of MSEs related to their transgender/nonbinary identity (k = 90, 67.69%). The next highest category of reported MSEs related to multiple identities (k = 16, 12.03%), for example, one client described experiencing discrimination at a club due to both their race and gender simultaneously. MSEs on the basis of other single identities were also identified by participants, which included: sexual identity (k = 15, 11.28%), disability (k = 7, 5.79%), race (k = 4, 3.01%), and gender (not transgender-specific) (k = 1, 0.08%).

Client-Therapist Interaction

Out of the 133 coded MSEs, clients were the first to discuss MSEs 90.22% of the time (k = 120). Follow up codes indicated that therapists did not always recognize that an MSE was being described, or provide an intervention for the MSE when it was mentioned by clients, in fact, therapists only provided specific interventions or responses to MSEs 67.67% of the time (k = 90). As noted in the method section, intervention was defined as an intentional therapeutic tool used to address, acknowledge, and or deepen the conversation regarding the minority stress event. In instances where the therapists did provide an intervention, the most common client response was to engage with the therapist in the intervention (k = 64), followed by the client changing the subject (k = 17), minimizing the experience (k=15), and/or providing a rationale for the person/institution involved in the minority stressor (k = 4) (note that percentages are not included due to multiple codes being possible on this option).

Clinical Exchanges

To illustrate examples of how clients discuss MSEs with their therapists, we offer atwo exchanges below. All clients are described with pseudonyms and identifying information has been excluded from exchanges. Client demographic information was provided by clients regarding how they wanted to be described in published research. Clients provided informed consent to have their clinical work coded and transcribed for research purposes.

For this first exchange, Clarissa, a 28 year old White butch lesbian trans woman mentions in her first session with her therapist about the complicated nature of integrating her sexual identity and trans identity. Clarissa had been randomized to the trans-affirmative therapy condition and her therapist was an advanced doctoral student who identified as White, cisgender, and heterosexual and whose theoretical orientation was psychodynamic. This exchange occurs 8 minutes into the first session when Clarissa is explaining what she would like to talk about over the course of therapy:

Clarissa: Facebook, text, skype. I text her [romantic partner] all the time when I leave the house. I spend way too much time in my room and it is mostly because I don’t like the looks I get often in public and I don’t really have any reason to go out, so why do it.

Therapist: That piece stands out to me that you feel uncomfortable that people are giving you looks and it isn’t pleasant when you’re out.

Clarissa: Yeah, but it has been happening ever since I started transitioning, so…which was almost 11 years ago.

Therapist: Wow, congrats-almost 11 year anniversary. It might helpful for me just to hear more about that process for you and especially where you are. I think when it comes to the therapy that we do here, I think you know, I want to work to sort of be aware of how identity might impact some of the things you’re coming in with, but at the same time, everyone’s story is different, just like any identity—it might not have anything to do with what is going on with you. I might ask questions of you at times to see “is it relevant?” “is it not?”

Clarissa: Understood. It probably is relevant, because even though it is more like my…I’m trying to figure out how to explain this because I have a very strained, not strained, but it is a complicated relationship with my own womanhood. Both because I’m a lesbian and because I’m a trans woman and that’s, according to society, that’s not what a woman is. And, so it is, the only thing that makes me feel more like a woman is the fact that I love other women. And that is also tied into my butch identity, which has complicated things in my transition because now I used to know I wanted, like GRS [gender reassignment surgery], but now I’m not sure because of the aftercare that is involved in that.

In this exchange she does not label the internalization she described in response to the distal MSE (e.g., people staring at her), but it does capture her beginning to verbalize her “complicated relationship to womanhood,” which is steeped in both gender role expectations and societal expectations of sexual identity. The therapist in this example was trained in transaffirmative therapy (TA)—in which therapists are trained to share with clients in the first session that there is no one way to have a “trans” narrative and that clients would have agency in what they were able to talk about in session, regardless of its relevance to gender. This specific intervention seems to have allowed Clarissa to open up with the therapist to let her know that she is finding it challenging to navigate messages about how to be both a trans woman and a lesbian at the same time, with the assumption that one cannot be both (from a societal message perspective).

This next example captures an exchange about MSEs, this time introduced by the therapist based on what the client had shared in a previous session. This exchange occurs in session 5 (a midpoint of the psychotherapy trial). The client in this exchange, Akela, is a 28 year old person who mostly identifies as nonbinary (“but sometimes more agender or genderqueer or genderfluid”), Indigenous [specific affiliation redacted for confidentiality] and White, and queer/pansexual. The client had been randomized to the BAMS+TA group and their therapist was a White, cisgender, queer, advanced doctoral student whose theoretical orientation was psychodynamic.

Akela: I feel oddly incompetent at this job and I also don’t like it so I don’t feel terribly motivated to be better at it, um, it is a [specific type of work], it is weird because I’m, the point of it is that it is a three year position and this is the first year and we’re supposed to get general experience and then after that I get to sort of specialize, but I already know where I want to work and it is the total opposite from where I am, so it is weird to invest a lot of time in learning how to do things when I have no intention of ever working in an environment like this ever. I just can’t get myself to care. I feel stressed out that I feel bad at it, but I also am grumpy that they didn’t offer me real training.

Therapist: Yeah!

Akela: Everyone keeps being like, oh well, “Cesar” was a super go-getter and did it all himself. I’m just like, that’s great for “Cesar”, but I don’t do that. I’m not like a, I don’t know, I’m not that extroverted or high energy or my learning style isn’t like, let me just learn and explore it myself. I like rules and structure and workflows and then try to find a better one for myself with clear boundaries and structure and it is very not structured.

Therapist: Yeah, you’ve also had some really demoralizing experiences around gender, race, ethnicity…

Akela: Yeah, that doesn’t help. It is still weird. I have all of these pictures that I’ve saved from the awful luau events and my coworkers hanging out leis and wearing floral shirts and having a good time and this is the same people who this year have been like, “Oh, I knew it was bad, I should have said something, I don’t know why I didn’t, I’m so sorry” and it is like, “You could have said something, I’m not going to absolve you now, you’ve had years of opportunities, like four years.” So I also, I feel ignored by a lot of my coworkers.

Therapist: That makes sense just from those experiences alone why you might not feel like you want to be there on top of the fact that it is not really the work that you want to be doing.

Akela: Yeah, but it still unfortunately reflects on me, which is the part that I don’t like (laughs). I am always overcompensating by doing professional development things and like, sign up to present at conferences and like, this book chapter thing, and now I’m just stressed out that I have all of this other stuff to do. I have a book chapter due next month and then a week after that I have a presentation and then in like two months another presentation. I think that I was trying to compensate the fact that I wasn’t doing any work and I want it to show that I’m doing something. I over-did it and I don’t feel terribly. I don’t actually want to go to the [name of] Conference. I know it is going to be uninteresting and frustrating.

Therapist: What would be frustrating?

Akela: Always these sessions on diversity and always by White people for White people and it is always set up like, we are [profession]. Their advice is never very good and always very self congratulatory and the amount of diversity people think is like acceptable is weird…

Therapist: Right, it shows how Eurocentric it is.

Akela: And I don’t want to be frustrated, so I don’t think I actually want to go. But, I think I have enough other conference presentations coming up that I can still look impressive and improve my resume without doing this one.

In this exchange, the therapist ties in a hypothesis about why Akela might not be motivated to engage in their work and it seems like the client felt heard about their previous experiences around their race and ethnicity which allowed space to process their experiences. Prior to starting therapy, Akela had specifically mentioned that they were disappointed in previous therapists’ inability to talk about race and gender and was not feeling hopeful that it would be possible to connect with a therapist on these issues. In this session, they seemed not only to open up about their experiences, but their exchange also seemed to capture a level of trust they had with their therapist by expressing a degree of vulnerability. They continue:

Therapist: Where do you see yourself?

Akela: I’d love to not be in the Midwest. I haven’t thought that much beyond it…something where I’m focusing on history and marginalized groups, but in [specific area]. Sort of helping ensure that the most marginalized of those marginalized groups that they are still included in archives is important, just helping unfortunately to legitimize history by just having it in the library makes it instantly more reliable even if it is just an oral history, somehow that is more reliable than that same person talking to you over coffee. I don’t know how, but somehow it is (laughing).

Therapist: Right, it is this continuation of oppression about what “counts.”

Akela: Yeah.

Therapist: Somehow more important or valid.

Akela: And since I can’t tear that down I’m trying to at least make things be included. So that’s the goal, I guess if I can handle being in [industry] for that long. It is just a very White profession, it is just like 85% White was the most recent statistic. And its not getting any better. The trend for recruitment it is like, um, [profession] just have this special problem with Whiteness and colonialism and even though they like upped recruitment a lot, retention is really bad so folks are just like, leaving the profession at the same rate they’re being recruited.

Therapist: Folks of color?

Akela: Yeah. So, that’s a bad sign (laughs).

Therapist: Yeah, that speaks to how hostile and toxic it is.

Akela: Yeah. But [professionals] don’t really, like they talk about diversity a lot but it is always the wrong way. It is more about retention or like, what if we got some [resources] about people of color and put them on shelves where people can see it. It is like, it is weird stuff or its like, trainings, like there’s trainings about everything.

Therapist: How can we play lip service.

Akela: Yeah, a checkbox, now we know what cultural appropriation is… (sarcastic voice)

Therapist: …As we put on our leis (sarcastic voice).

In this exchange, the therapist specifically names the oppression that the client is mentioning and deepens the discussion by pointing out characteristics of White supremacy, such as what is upheld or lifted in professions as being important. As Akela makes a joke of the lack of people of color in their field, the therapist further deepens the dialogue by naming the toxicity of the situation which allows space for Akela to process some of the reasons why their experiences at work have felt invalidating.

Akela: Right, so it is exhausting and like, even though I’m not the diversity resident I’m not actually supposed to do diversity work, I’m just to help “diversify the profession,” but there is no way to not do diversity work because someone else will do it or do it badly or they won’t do it

Therapist: Or I imagine they might ask you to do it too

Akela: Yeah, people still do that and they’re like “You don’t have to, but do you want to do this?” So then you’re like, if I don’t who will??

Therapist: It is like this, obligation.

Akela: Yeah. Yeah. I mean, obligated…it is hard when you have like, when you don’t even have the power to change things because they aren’t actually going to change but you think you have the power to change things and then you say no and when it keeps happening you think, I could have fixed it somehow, but like, you can’t actually because you can’t make people stop microaggressing you or stop being racist. They have to want to do that and even then, they’re still going to keep doing it. So it is just a lot of work.

Therapist: It sounds exhausting.

Akela: It is pretty exhausting and I don’t think that (city) is super unique in this way, but it seems to be a little bit like this sort of, this extra aspect where it is not even that people don’t care about diversity or care about social justice, everyone wants you to know they care so it is like this on top of the like, everyone wants to be patted on the back or absolved of like not doing more or like they want to say stuff like, “Well let me know if you want me to do anything to support you” instead of just supporting me [therapist says “supporting you” at the same time]. So it puts more on me where I have to let everyone know they’re the good White person or I have to like, instruct them on how to support me and then like, they still don’t. And then they complain to me about more things and then I’m more exhausted because it is another thing…

Therapist: On your plate…

The naming and validating and deepening work that the therapist has created space for in the session seems to have allowed Akela to name and process some of the emotional work that goes into what it is like for them at work every day. The naming of the exhaustion also seems to lend to providing specific examples of not getting their needs met and naming what they actually need from coworkers (and possibly their support system in general).

Akela: Yeah, it happens a lot less to the diversity resident. I think she gets more like overt microaggressions because I think that her ethnicity is a lot more obvious so people know the shitty microaggression to say to her, but she um, but I think that I already have this reputation for being this like, angry person who calls everyone out.

Therapist: So people interpret you calling them out or calling them in as being angry.

Akela: I think some people think that I’m angry or unreasonable or that I like won’t let stuff go with the luau stuff that has been going on. I had to prod at them a lot to get them to write an apology and then fix their apology and then fix it again and then it wasn’t even good and then keep reminding them that they said they’d do training and then like sending them articles because they said they couldn’t find articles somehow because they said they couldn’t find articles about appropriation of Hawaiian culture.

Therapist: That is so shitty.

Akela: Yeah, and not getting invited to conversations about it and like, being invited to private conversation about why I wasn’t invited to the private conversations and it is just like this, hounding these people because they won’t do it and it makes them feel more justified in writing me off because I’m just like, “they’re doing so much and I keep asking for more” because they’re not doing good work because I’m asking for more. At [building name] folks are more willing to talk about diversity and social justice and inclusivity but they also are like more fragile if you tell them they aren’t doing a good job so there is this extra [urban midwestern city] reputation that they are “so good at it” that you have to like, pat them on the back when you criticize them.

Therapist: It is unique form of White fragility when you add this layer of like, progressive (city).

Akela: Yeah, so it is like and they keep reminding me that “oh it is so lucky you’re here” because the other [buildings] are so much worse and I don’t feel lucky (laughs). I have to go to the basement to go to the bathroom.

Therapist: Right, none of that is luck.

Akela: The other [buildings] actually have gender neutral restrooms and sure, they might not have like meetings about diversity or something, but I don’t know.

Therapist: It sounds like maybe there is a piece where people are focusing on one aspect of your identity rather than focusing on you as a whole person.

Akela: Right and I don’t want to be this grumpy trans person where I have to constantly be like, did you know there are other genders? All of the time.

Therapist: I think it goes without saying that when you said grumpy, to maybe reframe that as justified anger.

Akela: Yeah. I feel justified but it is how people perceive me and it does make my interactions feel strained sometimes. And it is like weird to have to like, um, email the reference desk to say, don’t schedule me with these people because they like, always misgender me and I prompt them and they don’t care or they say racist stuff.

In this exchange, the therapist is attempting to help the client reframe people’s assumptions around Akela being the “angry” person of color by asking more about their interpretations of people’s perceptions, as well as reflecting how awful the situation must be for the client. This allows the client to share additional situations in which they are perceived this way, which highlights the ways in which the systems Akela is a part of continue to isolate them and make them feel “othered.” Othering is defined as actions or communication that uses power to specifically create and “us” vs. “them” dynamic (Inokuchi & Nozaki, 2005). In this example, specifically acknowledging the anger and the oppressive systems was part of the healing process when Akela was feeling othered.

Discussion

The main aim of the current study was to create a coding scheme to capture the process of how minority stress experiences (MSEs) are mentioned and how the client and therapist interact with one another regarding MSEs. This primary aim was met, but not without some limitations. The coders had a range of agreement, with the lowest being at 70.42%. Percent agreement is the single most widely used index in inter-rater coding (Lavrakas, 2008); agreement that is 80% or more is considered highly reliable, thus some of our coding categories fell slightly short of this. However, part of the explanation for this is that coders could code more than one MSE for the same exchange (for example, if a client brought up experiencing harassment and then sharing how they internalized the harassment this would be coded as both a distal and proximal stressor). As well, coders noted the ease of coming to agreement on categories when discussing concepts together, which lends to a possible procedural component of coding psychotherapy sessions in tandem. Qualitative research has a strong base in using both individual and collaborative coding (e.g., Charmaz, 2012; Hall et al., 2005), of which quantitative coding researchers may incorporate. Of note for the coding scheme, the coders were able to reach acceptable agreement on most categories, with the exception identified above. In the coding scheme, coders were set to code if it appeared that the client was satisfied with the exchange between the therapist and client when an MSE arose. Despite many conversations and workshopping how to code for satisfaction, we were unable to derive a definition and agreement for determining observed client satisfaction with the MSE intervention. Thus, no results were reported or interpreted for these codes.

Despite these limitations, results from the present study yielded a wealth of information regarding the extent to which and how discussions about MSEs occur in psychotherapy. First, all clients mentioned at least one MSE in the three out of a possible 12 sessions that were coded. While this was not surprising for the clients who had been randomized to the Building Awareness of Minority Stressors (BAMS) group, it is notable that all of the clients in the TransAffirmative (TA) therapy group brought up MSEs as often as in the BAMS group. With the frequency of minority stress experiences reported by TNB people in the literature (Testa et al., 2017), previous research supports this finding. However, this finding adds to the literature by noting a) that MSEs do arise in therapy, and b) for most clients, they came up several times throughout each session.

The single most frequent category that arose in sessions was clients describing prejudice they had experienced and that most of these prejudice experiences were related to their trans or nonbinary identity. The US Trans Survey (James et al., 2016) indicated that anti-transgender prejudice is pervasive in almost every system—employment, family, housing, prisons, church, etc. Anti-transgender prejudice has been found to be related to cisgender people’s gender role attitudes, need for closure, right-wing authoritarianism, and contact apprehension (McCullough et al., 2019; Tebbe & Moradi, 2012). To reduce the effects of these, studies have noted that some attempts to reduce anti-transgender prejudice in cisgender populations have yet to be effective (Tompkins et al., 2015). Although anti-transgender discrimination experiences have perhaps been researched on a greater level than prejudice experiences (see James et al., 2016) – likely due to the ready behavioral operationalization of discrimination – clients in the present study discussed experiencing prejudice with their therapists at far greater rates than discussing experiences of discrimination. We suspect that therapy provided clients the unique space to process the bias they were experiencing from others. It is not surprising that harassment was listed as the least frequent distal MSE. Research supports the concept that the most overt forms of harassment occur less often because of the lack of anonymity involved (e.g., Fox et al., 2015), although these events still occur regularly for TNB people (James et al., 2016).

Internalized stigma was the most frequently reported proximal MSE, with the majority of these experiences relating to internalized transnegativity (IT). Research has demonstrated that IT mediates the relationship between distal stress and mental health concerns (e.g., Staples et al., 2018); however, this is the first study to demonstrate the nuance of how these factors are described in tandem, especially in the context of psychotherapy. Rumination on distal stressors was the second most frequent proximal stressor to arise in sessions. However, literature on this concept is sparse for TNB-focused rumination. Timmins and colleagues (2017) found that general rumination mediated anti-transgender prejudice and distress, though rumination was operationalized generally, rather than as rumination specifically related to distal stressors. Other rumination research with TNB populations has focused on TNB people’s rumination related to their gender identity (e.g., van der Brink et al., 2019). In van der Brink and colleagues’ study, they found that rumination was related to distal stressors, underscoring the importance of understanding how and why rumination occurs for TNB people. Fear of rejection and identity concealment were the least frequent proximal MSEs described by clients in their sessions in this study. Qualitative research demonstrates that TNB people describe fear of rejection regarding both a) where they expect to experience rejection and b) their emotions in tandem with the fear of rejection (Rood et al., 2016); however, how and why this arises in psychotherapy remains unknown. As well, concealment is poorly understood in the literature and is more nuanced than in the LGB literature (Puckett, 2020); however, research demonstrates that TNB people make decisions about concealment based on context and may be influenced by each person’s own experiences with “blending” their gender (Rood et al., 2017). It is our hope that understanding that these events arise in psychotherapy will provide a lens through which psychotherapy interventions can be created to address each of these MSEs.

Although understanding the frequency of events can assist with a base understanding of whether or not these events arise in psychotherapy, what can provide more impact is the actual process that unfolds once these events arise in psychotherapy. According to our data, clients are the ones who typically bring up MSEs in session and therapists recognize and respond almost two thirds of the time. Unfortunately, however, that also means that one third of these events are being missed by therapists. Studies that focus on therapist microaggressions and missteps in therapy demonstrate that therapists struggle with either an underemphasis or an overemphasis on gender in sessions with TNB clients (Mizock & Lundquist, 2016; Morris et al., 2020). It is possible that the therapists in these sessions did not want to perpetuate overemphasizing gender, but what is more likely is that therapists simply missed opportunities to discuss the MSE. This finding demonstrates a need to train therapists on minority stress theory and providing specific markers in sessions for when and how to intervene.

Finally, we aimed to demonstrate that MSEs for TNB people are complex and should not be assumed to only focus on their TNB identity. In an effort to avoid the pitfall that many psychological researchers have fallen into with intersectionality research, we aimed to describe MSEs with nuance and from a lens that uses both strong and weak intersectionality (see Adames et al., 2018). With this aim in mind, while we reported frequencies of the identities that were related to MSEs described in session, the intersectional lens that we choose to use is focused more on including clients’ descriptions of their experiences and considering how power, privilege, and oppression intersect related to each person and to the collective whole of clients. From a weak intersectionality standpoint (Adames), it is unsurprising that the majority of MSEs were described as transgender-specific events—it is possible that clients mentioned these because they had enrolled in a study that specified a focus on TNB clients, it could be that TNB identity was most salient for most of the clients, or it could be due to an additional unexplained factor. From a strong intersectional standpoint (Adames), we provided two examples of clients who are actively trying to navigate systems of power—specifically ones that share explicit, oppressive messages about race and gender expectations and the challenges of navigating these with therapists who do not have shared lived experiences of these messages.

Limitations and Future Directions

There were several limitations to the current study. As there is limited research related to minority stress and psychotherapy with TNB clients, creating a coding scheme was a challenging process. We did not create a specific rating for how the therapist may have negatively intervened, which should be included in future iterations of the coding scheme. We did not reach the desired inter-rater reliability on each factor, likely due to more than one category being allowed to be coded at one time. Future iterations of the coding scheme may involve a design that does not allow for more than one category to be coded at one time to allow for simpler agreement coding. However, it may also be that future research begins to break down barriers regarding perceived objectivity of coding and take note from decades of qualitative research that centers the positionality of the researchers for an understanding of how the codes are interpreted for replication purposes.

The sample in this study reflects the majority of TNB research—the majority identifying as White. Rather than provide explanations for why this occurred, we stand to correct this limitation of the current study by conducting our next psychotherapy research project by centering BIPOC TNB people at every stage of the process—from who is involved in the design, to who is doing the therapy, to who is involved in the therapy. There are decades of analysis for why BIPOC people may be reticent to participate in research and breaking down these barriers means the research team reflecting on their own identities and who is included in the work from the beginning. Although BIPOC people were involved in each stage of this study, a decolonized lens indicates that involvement is not enough (Tebbe & Budge, 2016).

An additional limitation of the study was the sample size. The aim of the overall study was to determine the feasibility and acceptability of conducting a randomized controlled trial with TNB populations (Budge et al., 2020), which guided the sample size. As a secondary aim, we used the video data to create a coding scheme for the current study. However, a larger sample may demonstrate differential processes regarding the number and type of MSEs as well as how therapists respond. Future research could focus on creating interventions for specific MSEs and training therapists on MSEs; this coding scheme could be adapted to address fidelity to the interventions.

Implications

It is our hope that the primary outcome from this study is that interventions will be created to assist TNB clients in processing MSEs in (and out) of session. Non-psychotherapy interventions have focused on psychoeducation related to minority stress in general (see Austin et al., 2018; Israel et al., 2020) and Budge and colleagues (2020) created a psychoeducational tool for psychotherapy clients to learn about minority stress to be able to discuss it in psychotherapy sessions. However, the most useful tool that could be created from the information obtained in this study would provide specific interventions for each type of MSE. The training for therapists should focus on specific MSEs with definitions and examples of how clients bring up these issues in therapy. As well, therapists will be trained on specific ways in which to intervene in those moments, especially when they are not sure if clients would like to discuss the MSE.

Beyond training and interventions, it is also important for therapists to understand how multiple systems of power interact with their TNB clients’ lives. Relatedly, it is important for therapists to acknowledge their own relationship with these systems of power and how they might interact with the client, the therapeutic relationship, and with the presenting concerns the client brings with them into the therapeutic context. At the time this psychotherapy study was underway, the Trump administration was specifically targeting TNB populations on a widescale (see dickey & Budge, 2020 for a review). The APA Guidelines for Psychological Practice with Transgender and Gender Nonconforming People (2015) specifically note the importance of mental health professionals’ role in advocacy with TNB clients. Although a therapist may be able to reduce distress in the moment with one-on-one (or additional therapy modalities) with TNB clients, therapists can also engage in advocacy that may assist with reducing MSEs in general with their clients. For example, therapists can educate insurance providers about expanding their access to gender affirming care for TNB clients, draft local legislation for protections for TNB people, or donate to organizations committed to improving the lives of TNB people (as several small examples).

Clinical Impact Statement.

Question:

This study aimed to determine if there is a reliable way to code observations of minority stress experiences (MSEs) in psychotherapy with transgender and nonbinary (TNB) clients.

Findings:

Researchers designed a coding scheme that appears to accurately reflect which MSEs are discussed in psychotherapy sessions and how clients respond to therapist interventions regarding MSEs.

Meaning:

Clinicians can meaningfully use the data from this study to determine if and how they are responding to client minority stress experiences. They can use the clinical exchanges to improve their knowledge, awareness, and skills related to MSEs for TNB clients.

Next Steps:

Future directions for this research includes the creation of interventions and trainings to assist therapists with effectively responding to MSEs in session with clients.