From distance to resonance: A qualitative study on overcoming countertransferential anxieties in therapy with transgender and nonbinary patients

Background: Transgender and nonbinary (trans)individuals often face stigmatization, pathologization, and misrecognition in psychotherapy, negatively impacting their mental health and access to care. Despite growing attention to countertransference (CT) in psychotherapy, little is known about the CT reactions experienced by cisgender therapists when working with trans patients, and how such reactions evolve over time. Aim: This study investigates the emotional and countertransferential experiences of cisgender psychotherapists working with trans patients, aiming to illuminate the anxieties, defenses, and reflective processes that influence the therapeutic relationship. Methods: Twelve Italian cisgender psychotherapists from various theoretical orientations participated in 90-minute semi-structured interviews. All had prior experience treating at least one trans patient. Data were analyzed using interpretative phenomenological analysis. Results: Four major themes were identified: (1) Therapists’ initial expectations and concerns, often marked by hyper-gendered fantasies, insecurity, and fears of incompetence; (2) Therapists’ emotional responses during sessions, including urgency for definition, rejection, somatic countertransference, guilt, and moments of attunement; (3) Therapists’ reflections on the topic of gender, revealing the need to slow down the process and interrogate their own gender positioning; and (4) Therapists’ considerations on language use and meaning-making in therapy, marked by tensions between inclusive practice and unconscious essentialist assumptions. Discussion: Findings revealed how trans patients evoke complex emotional dynamics in cisgender therapists. When adequately processed through supervision and reflection, these dynamics may foster self-awareness, therapeutic resonance, and more affirming clinical practice. The study underscores the importance of specialized training and supervisory frameworks attuned to the authentic needs of trans patients.