GRACE: A Family Therapy Model for Transgender Youth
and Their Families
Ashley Martin-Cuellar, Ph.D., LMFT
& Zoe Cornwell, LMFT
OUTLINE
Outline
• Brief Primer/Introduction: Gender Unicorn
• Challenges facing parents of transgender and gender
variant youth
Theoretical foundations
Family Therapy
GRACE Model
GRACE Model Interventions
Vignette example/discussion
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Question: We first want to assess…
• How many of you have worked with transgender individuals?
• How many of you have worked with transgender youth and their families?
Definition of Terms
Gender Identity: a person’s deeply felt,
inherent sense of being.
Sex: is typically assigned at birth based on
the external genitalia.
Sexual/Affectional orientation: A
component of identity that includes a person’s
physical and emotional attractions.
Transgender: an adjective that is an umbrella
term used to describe the full range of
people’s whose gender identity and/or gender
role do not conform to what is typically
associated with their sex at birth. Not all
TGNC self-identify with this term.
Cisgender: An adjective to describe a person
whose gender identity and gender expression
align with sex assigned at birth.
APA, 2015
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Honoring someone’s name.
Navigating mis-gendering
someone.
Its important to ask and not
assume someone’s
pronouns.
Names and
Pronouns
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Mental Health Concerns
Being transgender is not a mental health concern, transgender youth
have a variety of mental health concerns as a result of:
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Minority stress1 – Transgender people are of a minority group; they encounter minority
stress (loneliness associated with feeling disconnected from dominant group)
Lack of social support2 –due to stigma and judgement attached to being transgender
Discrimination2 –for being transgender (housing and employment protections for example)
Struggles with “Passing”/Blending– not just that people will make comments and laugh,
but that they could be killed
Concerning Family and Relationships
• Worried about impact on family and friends and the fear of losing them
• Fear of rejection
Disclosure process can be challenging
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As a result of these struggles and challenges, self-harm and/or suicidal
ideation may be present.
1. Meyer (2003)
2. Lombardi (2001)
3. Bockting, Robinson, Forberg & Scheltema, 2005
Benefits of Supports
• Transgender children with supportive caregivers have fewer depressive
symptoms, higher life satisfaction, and lower perceived burden of being
transgender1
• Socially transitioned youth with family support have similar rates of
depression and life satisfaction as cisgender youth2
• Family support is the strongest protective predictor gender nonconforming youth outcomes3
1. Simons, Schrager, Clark, Belzer, & Olson (2013)
2. Veale, Peter, Travers, & Saewyc (2017)
3. Durwood, McLaughlin, K., & Olson (2016)
Theory
Our Theoretical Orientations/Foundations
• Systems Theory
• Gender Affirmation
• Ambiguous Loss
Gender Affirmation Theory
• Affirmation counseling begins with the premise that individuals have the
right to self-determination (i.e., asking about pronouns, asking about the
individual’s goals for counseling…)
• All ways of experiencing and engaging one’s gender are acknowledged as
equally valuable1
• Trans-affirmative practice refers to a non-pathologizing approach to clinical
practice that accepts and validates all experiences of gender2
• Affirming therapists assume that gender is fluid and variance in gender is
as natural as any other expression of gender2
2. Lov (2004)
1. Austin & Craig (2015)
Gender Affirmation Theory
• Affirmation begins with examining our own biases and our realization that
as members of a heterosexual society, we all bring our heterosexual
biases to our work as therapists. 1
• Affirmation begins before we even know the client…2
1. Bieschke, Perez & DeBord (2007)
2. Matthews (2007)
Ambiguous Loss
• Loss in which absence and presence are not absolutes.
• First, we need to identify the type of loss the person is dealing with:
– Psychological absence with physical presence (i.e., divorce, drug
addiction, dementia)
– Physical absence with psychological presence (i.e., kidnapping, POW)
• Family with a transgender child are facing the first type because they have
lost a role (a gender role and related expectations), but still have the
person present.
Boss (2006)
Ambiguous Loss
• Ambiguous loss is inherently traumatic because the inability to resolve the
situation causes pain, confusion, shock, distress, and often immobilization.
• Without closure, the trauma of this unique kind of loss becomes chronic.
• However, in the process of finding closure we often do damage because
some events defy easy closure (not acknowledging the ambiguity).
Boss (2006)
Ambiguous loss and families with a transgender
member
Finding Meaning
Tempering Mastery
Reconstructing Identity
Normalizing Ambivalence
Revising Attachment
Discovering Hope
Boss (2006)
• Ambiguous loss stems from a systems perspective and can inform our
therapeutic work with transgender clients and their families.
• Ambiguous loss was specifically designed as a family and communitybased intervention.
• There are 6 guidelines for intervention:
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Reconstructing Identity
Three main questions to address in therapy:
• Who is in the family, and who is out?
• Does everyone have to be, or do, the same thing they always did?
• Can people trust the world outside of their home?
The answers to these questions will change when a child comes out as
transgender.
Boss (2006)
Normalizing Ambivalence
• The therapeutic goal is to normalize ambivalence so as to lessen guilt and
increase resiliency.
• Normalizing grief related to the loss of gender roles and expectations.
– This means acknowledging its existence: once recognized people can
and do cope with this tension
Boss (2006)
Transgender
Emergence
Lev (2004)
Stage 5: Exploration:
Transition
issues/possible body
modification
Stage 3: Disclosure to
significant others
Stage 1: Awareness
Stage 6: Integration:
Acceptance and post
transition issues
Stage 4: Exploration:
Identity and selflabeling
Stage 2: Seeking
information/reaching
out
Family
Emergence
Stages
Lev (2004)
Stage 4
Stage 3
Stage 2
Stage 1
Finding Balance
Negotiation
Turmoil
Discovery and Disclosure
The Complexity of Family Therapy
• There are a several things going on simultaneously in a family therapy session.
• The different emergence stages of the transgender individual
• The different emergence stages of the family
• The developmental age/stage of the transgender individual
• The developmental age/stage of the family
• Sibling reactions
• As the family therapist you are navigating all these processes simultaneously.
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Family Therapy
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They may want the mental health clinician to “fix” their child
Looking for acceptance as parents
Looking for affirmation
Looking for guidance
They may wonder what they did wrong
They may want to learn how to best help their child.
Parents/caregivers may come to counseling for a variety of reasons
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Korell & Lorah (2007)
Family Therapy
• Family members go through their own unique process of “coming out” as they come to
terms with a loved one’s transgender identity, this process differs from the transgender
individual’s process1
• Goals of family therapy include:2,3
• Facilitating dialogues2,3
• Increasing acceptance and support
• Reducing rejection
• Family psychoeducation to provide accurate information
• Teach coping skills and problem-solving strategies for dealing with challenges
• And improving management of conflicts or misinformation that may exacerbate an
adolescent’s distress.
1. Korell & Lorah (2007)
3. Salzburg (2007)
2. Mattison & McWhirtier (1995)
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Not every session
has to be with
every member of
the family present
Family Therapy
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Family therapy
can be seeing one
individual with the
family system in
mind.
Family Therapy
mechanics/structure:
Individual with youth
Family with youth
Family without youth
GRACE Model
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Grace is compassion for self and
compassion towards others. Showing
grace is allowing someone their process
and their experience as well as working
towards understanding and
reconciliation for mistakes.
GRACE Model Assumptions
• Assumption 1. Families struggling with the transition of their child are not
doing so because of malintent, but to keep their system stable.
• Assumption 2. Dysfunction is a result of misunderstandings that
deserve/requires an openness to resolve.
• Assumption 3. Listening to understand and not to respond is what brings
about change within the system.
• Assumption 4. Processing and change within the system takes time.
• Assumption 5. Parents and caregivers love their children and are trying
to do what’s best in their mind and are operating with that intention.
GRACE
• Is not a manualized
protocol but aims to
identify core components
of treatment.
• GRACE identifies key
targets of intervention
• GRACE is a lens to view
and assist the youth, the
caregivers/family and as a
reflection lens for the
therapist.
Gratitude: Love, care and appreciation
Respect: Emotions/feelings/boundaries
Affirmation: Language and pronouns
Connection: Building closeness
Education: Resources and Realities
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Connection: Connection is also action oriented. Connection takes intention and
humility. It takes regulation2 and vulnerability3. Connection is bringing about new
family identities, values, and behaviors together.
Affirmation: Affirmation is an active concept, meaning it takes action to validate
another person and who they are. Affirmation comes through our words and actions.
Respect: Respect includes the way we talk: the words we use and the tone, as well
as our non-verbal communication skills including the focus and intent in which we
listen. Respect honors a person/family’s emotions, feelings and process.
Gratitude: Gratitude as a psychological state is a felt sense of wonder, thankfulness
and appreciation for life1
GRACE Model: Key Targets of Intervention
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Education: As Maya Angelou famously stated, “when we know better, we do better.”
Education is about providing information and being open-minded and invested in
taking time to educate and understand another’s experience.
2. Schore & Schore (2007)
1. Emmons & Shelton (2003).
3. Jordan (2008)
GRACE Model: In Practice
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Parents/Caregivers
Interventions
Gratitude Interventions
Youth Interventions
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Supporting youth in
gratitude towards
caregiver for being
invested in therapy/or for
attending therapy.
Supporting youth to
appreciate who they are
and the uniqueness they
bring to the world.
Supporting
parent/caregiver in
gratitude about their child
and their child’s process
Supporting
parent/caregiver appreciate
their child for who they are
and the uniqueness they
bring to the world.
Therapist Interventions
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Gratitude for family involvement.
Appreciating the family progress
as it occurs.
Gratitude to youth for their
investment in working with their
family.
Appreciating the youth around the
difficulty of this process for them.
Appreciating the caregiver(s) for
their time and investment in their
child.
Gratitude for the caregiver's
honesty about their
emotions/feelings.
Gratitude for youth’s honesty
about their emotions/feelings.
Parent/Caregiver Interventions
• Bringing ambivalent feelings
out in the open1
• Managing ambivalence once
aware of it (coping strategies) 1
Respect Interventions
Youth Interventions
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Discussion about
caregivers' emotions
and feelings.
Discussion about
respecting caregivers’
boundaries and
process.
Therapist Interventions
• Respecting the
family’s process.
• Respecting the
family’s boundaries.
1. Boss, 2006
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Telling different stories1
Exploring family themes about
gender1
Increasing tolerance to flexibility
in gender roles1
Reconstructing gender roles1
Parent/Caregiver Interventions
Affirmation Interventions:
Youth Interventions
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Discussion about their
preferred language and
pronouns.
Discussion about their
identity, how they see
themselves, who they are.
Discussion about
caregiver’s process and
family identity.
Affirming parents positive
progress in using
preferred name and
pronouns.
Therapist Interventions
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Hold family members
accountable in session,
point out misgendering,
etc.
Modeling use of pronouns
and language
Affirming family’s
strengths and progress.
1. Boss, 2006
Parent/Caregivers Interventions
• Discourage transmission of
hatred1
• Finding choices about family
values and identity1
• Your child is still your child! Find
new ways to connect.
Connection Interventions:
Youth Interventions
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Discussions about time
spent with
caregivers/family.
Discussions about the
importance of check-ins
Discussions about
closeness with
caregivers and barriers
to closeness with
caregivers/family
Therapist Interventions
• Hearing every family
member’s story
• Build rapport with all
members
1. Boss, 2006
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Parent/Caregiver Interventions
Education Interventions:
Youth Interventions
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Supporting youth to share
about personal process
as they feel comfortable
to educate
caregivers/family.
Support youth in seeking
out education to
understand hormone
therapies, surgeries, etc.
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Normalizing guilt, grief, and
negative feelings, but not harmful
actions1
Knowing that closure does not
lower ambivalence1
Assuming the world is not fair
and just1
Knowing that sometimes people
hide their identities for safety1
Helping caregivers seek out and
educate self on resources and
realities for their child.
Supporting caregivers in
advocacy.
Therapist Interventions
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Seek out and educate self
on resources and realities
for transgender people.
Seek out and educate self
on hormone therapies,
surgeries, etc. to assist the
youth in their education
seeking process.
Continue to seek out CE
opportunities.
Provide education to youth
and their families.
1. Boss, 2006
Vignette
Client is 12 years old, assigned male at birth. Recently in session the client
disclosed that he felt like he might be a girl. Family consists of mom and a
sister. Mom has been supportive of client’s sexual orientation as gay but
does not believe that client is “really transgender” as she believes the client
is a “joiner.” Client has a background of sexual trauma. Sister is very
unsupportive and makes fun of client’ s gender identity questioning. Client’s
father is not involved in the family and hasn’t been since he was born.
• What initial assumptions or biases come up for you?
• How might you think about this case within the lens of the GRACE model
interventions?
Conclusion: Action steps!
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Have your paperwork reflect that you are an affirmative
therapist!
We need more research! Especially on working with families…
Take what we have here, use it, research it, change it, adapt it…
we welcome critiques, adjustments and adaptations.
Share with others, so the onus is not always on the
transcommunity all the time.
How to talk (and listen) to transgender people
References
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Austin, A., & Craig, S. L. (2015). Transgender affirmative cognitive behavioral therapy: Clinical considerations
and applications. Professional Psychology: Research and Practice, 46(1), 21.
Bavelas, J. B., & Segal, L. (1982). Family systems theory: Background and implications. Journal of
Communication, 32(3), 99-107.
Boss, P. (2006). Loss, Trauma, and Resilience: Therapeutic Work With Ambiguous Loss. W. W. Norton &
Company: New York
von Bertalanffy, L. (1968). Organismic psychology and systems theory (p. 67). Worcester, MA: Clark University
Press.
Bockting, B., Robinson, B. E.., Forberg, J., & Scheltema, K. (2005). Evaluation of a sexual health approach to
reducing HIV/STD risk in the transgender community. AIDS Care, 17, 289-303.
Cohen-Kettenis, P. T., & Pfäfflin, F. (2003). Transgenderism and intersexuality in childhood and adolescence:
Making choices (Vol. 46). Sage.
Durwood, L., McLaughlin, K. A., & Olson, K. R. (2017). Mental Health and Self-Worth in Socially Transitioned
Transgender Youth. Journal of the American Academy of Child and Adolescent Psychiatry, 56(2), 116–123.e2.
http://doi.org/10.1016/j.jaac.2016.10.016
Grossman, A., & D'Augelli, A. (2006). Transgender youth: Invisible and vulnerable. Journal of Homosexuality,
51, 111–128
References
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Korell, S. C., & Lorah, P. (2007). An Overview of Affirmative Psychotherapy and Counseling With
Transgender Clients. In K. J. Bieschke, R. M. Perez, & K. A. DeBord (Eds.), Handbook of counseling and
psychotherapy with lesbian, gay, bisexual, and transgender clients (pp. 271-288). Washington, DC, US:
American Psychological Association.
Lev, A. I. (2004). Transgender emergence. New York, NY: Haworth Clinical Practice Press.
Lombardi, E. (2001). Enhancing transgender health care. American Journal of Public Health, 91(6), 869–
872.
Mattison, A. M., & McWhirter, D. P. (1995). Lesbians, gay men, and their families: Some therapeutic
issues. Psychiatric Clinics of North America.
Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations:
Conceptual issues and research evidence. Psychological Bulletin, 129, 674–697.
http://dx.doi.org/10.1037/0033- 2909.129.5.674
Simons, L., Schrager, S. M., Clark, L. F., Belzer, M., & Olson, J. (2013). Parental Support and Mental
Health Among Transgender Adolescents. The Journal of Adolescent Health : Official Publication of the
Society for Adolescent Medicine, 53(6), 1000-1016
Veale, J., Peter, R., Travers, R., & Saewyc, E. (2017). Enacted stigma, mental health, and protective
factors among transgender youth in Canada. Transgender Health, 2, 207-216.