Talk therapy at a crossroads

With Stella O'Malley on anxiety, the culture of optimization, why we embrace our diagnoses, and whether the so-called anti-conversion therapy laws will criminalize talk therapy

To the growing list of things that the most vocal of the present-day transactivists campaign against--comedy, libraries, fiction, feminism, rape shelters, sports divided by sex, biologists, clarity in medical communication—we can now add psychotherapy. The closing of the Gender Identity Clinic at CAMH a few year ago and the firing of Dr Zucker under activist pressure was a harbinger of things to come. Since then, jurisdiction by anglophone jurisdiction has been adopting the “anti-conversion therapy” laws, which are sure to put talk therapy under outsider scrutiny and open it up to vexatious litigation. And while conversion therapy for sexual orientation is easy to define, what is conversion therapy for trans-identification? Making someone accept and love their own body again? The issue is doubly complicated with adolescents and children. Nevermind that, said Canada’s Liberal government when it adopted its own anti-conversion therapy law recently. We don’t care that European countries are abandoning puberty blockers and re-examining their gender dysphoria protocols. We will plug our ears and press on, undeterred.

Therapists who are willing to speak out about this are few, because, well, see under Ken Zucker. Many see gender dysphoric kids who have a co-morbidity (autism, eating disorders, depression, and sometimes evident discomfort with one’s own same-sex orientation). Therapists ordinarily have the obligation to explore this in sessions, but the “anti-conversion” laws will make it impossible. Why are you dwelling on my depression if I am telling you that I am depressed because I am in the wrong body—I just need a transition pathway? Why are you asking about my child’s Asperger’s, when we’re here to cure their gender dysphoria by blocking their puberty? Conversations like these will multiply and the demands for immediate transition will have the weight of law behind them.

Not all therapists are silent, however. There are a handful who speak out in public fora and advocate for a more nuanced and slow approach. Among them is Irish psychotherapist Stella O’Malley who, together with her American colleague Sasha Ayad, presents the popular Gender: A Wider Lens podcast, under the auspices of Rethink Identity Medicine Ethics and Genspect, an international alliance of parent and professional groups whose aim is to advocate for parents of gender-questioning children and young people. O’Malley’s latest book is Bully-Proof Kids: Practical Tools to Help Your Child Grow Up Confident, Resilient and Strong. Having just read it, I started our Zoom interview by asking her how the book came to be.

SOM: There were two big reasons for this book. So many adolescents who come to see me would talk about either bullying or feeling excluded, and not really knowing how to operate in school and among their peers, in what feels like a pit of snakes sometimes. And the second reason is, so many adults in my clinical practice when I ask them, when did you first feel distressed, when did you first feel you lost your way, they would bring back bullying. “When I was bullied when I was eleven”. And I realized that this really lasts, it really has a long-time impact.

LP: That’s one of the things that stood out for me. And another thing that I’ve been thinking about a lot, is what you say about victimhood. When you see yourself as permanently victimized, you write, you’re giving away your power.

I wanted to use for example the word “a target of bullying”, rather than “a victim of bullying” just to make sure that you retain a kind of protectiveness around your experience. There’s a difference in the emphasis and I think it’s important that we keep ourselves centred.

Are we going in the direction of everybody feeling victimized, is that the spirit of the age?

I think it’s an issue. I think I traced it in and around 1990s. Medical model in many ways took over from psychology, with an awful lot of anti-anxiety medication, and medication for many different diagnoses; and this diagnostic creep happened around the same time. It became much, much easier to find a diagnosis. Now, I’m not saying it should be very difficult to get a diagnosis, but it certainly became very easy. So I often meet teenagers nowadays who will have five diagnoses, or three diagnoses. That’s not that uncommon. And that has created a world where you can effectively lean into your diagnosis, and I don’t think that it empowers us. Because a diagnosis isn’t necessarily a diagnosis for life. Some people do move beyond it. I think what happens fairly often with diagnosis is, it’s very empowering at the beginning. The parents feel a lot better, you get a lot more support, it really helps. And then you’re in your late teens and it doesn’t help, because you’ll feel limited by that diagnosis, and shaped by it. Some people are really impacted by it. What really worked at 11 won’t necessarily work at 19 or 25. And it can really shape your view of yourself.

And my impression is that we’ve all gotten more neurotic in American ways. There’s that famous book by Ethan Watters, Crazy Like Us: The Globalization of the American Psyche… We have all these handy American words to name our problems.

I agree. And it feels a bit money-driven. It feels like the medical model is making an awful lot of money for a lot of people, and when you’re tired or distressed we now presume you should go see somebody. And listen, I’m a therapist but I have to say, you need to re-consider that. When your child is distressed we should look at different things, maybe for example their friendships need a hand, maybe what they need to do is reconnect with their cousins that they used to get on with, as opposed to, you’re lonely so I’ll bring you to a therapist: that doesn’t necessarily work. That will just make you feel like “I’m a freak, I have to go to a therapist I’m so lonely”. We all have times like that. I certainly had times during my childhood where I lost my way, I lost my friends, and could have used a bit of help, but parents could do that; that doesn’t take a professional.

Have you noticed this, people are adding “neurodivergent” in their Twitter bios now, as a matter of pride or perhaps as a personality trait?

I did write about this in my other books, Cotton Wool Kids and Fragile. And both of them discuss this tendency toward… well, I’ve seen it in my own children. They happen to go to school where there’s an awful lot of diagnoses. The kids hide behind some of them. “My ADHD made me do it” type thing. My own kids have dyslexia and I’ve seen them fall into that. I’m Mrs “Don’t Use Your Diagnosis” and they both do, often. Because they’re of a generation where you brandish your diagnosis as a self-protective shield when you’re in trouble, and it works. So I saw my daughter become a bit of an expert in it, she’d whip out “my dyslexia made me do it” for random things. And I just see that they look around and they’ve learned. It’s the fault of a society that has made it so that if you’re neurotypical, a lot is asked of you. Maybe what we need to do is be more forgiving of everybody. And we should be saying, I’m human, that’s why I did it; because I make mistakes, because I’m fallible. As opposed to, I need to have an excuse. I think we expect an awful lot of everybody, so people fall into their diagnosis as a way to say, this is why I’m not coming up perfect.

I really think there’s a disease of perfection that we’re having to deal with, starting in childhood. Kids get interested in football and suddenly they’re on a football team, there are matches and scores, and a lot of emphasis on performance very quickly. They like ballet, they like dancing, and suddenly they’re up in a show, and I saw this in my children’s childhood. As soon as they’re invested in something, they become very professionalized very quickly. I remember seeing my kids, they didn’t really want to do the show, and it was all about the show the show the show… If you or I were up on the stage, dancing, tonight, we’d be nervous and unsettled. And nervous and unsettled for weeks if we knew it was coming.

There’s an awful lot of tension in childhood. So they fall into their diagnoses as a way to say, back off. And I get it. I get why they do it. But we need to call it when it’s happening.

So it’s kind of resistance against this demand for optimization. Always getting ahead, getting better numbers, better performance.

Exactly. Optimizing their academic potential, optimizing physical performance, everything. It’s never enough. It’s creeping up here too but I’ve seen it in America: it’s not enough that you’re brilliant at school. You also have to do charity work and you also have to do this and do that. These kids are so young, what would they be doing charity work for. Their heart wouldn’t be in it anyway (with the odd Mother Teresa as the exception that proves the rule). Most teenagers don’t have massive levels of charity work in them. Nor should they.

How is talk therapy viewed in Ireland? Is the Cognitive Behavioural Therapy the most popular method, like here, because it’s shorter and easier to fund? What’s the situation?

A lot more teenagers get therapy than ever before. I am not a child therapist, I see teenagers but not children, and generally child therapy would be play therapy. And that’s for children who’ve been severely traumatized. Something’s happened, and they go see a play therapist and use figurines to kind of process it. It’s a slow and reflective process. But there are children who go who haven’t been traumatized, they just want an easier life. There’s a well known therapist in Ireland who says, under 12 years of age, I see the parents. And I think that’s interesting. Apart from the cases where the child is traumatized, I think that probably has a lot more impact. As in, what’s going on, where do you need to lean in, what does the child need. Let’s have a concerted, reflective process on how you the parents can help this child.

I have a Masters in CBT. I think it could be very good for a number of people who like CBT, and then there are people who come in and say, you can do what you want but don’t give me CBT, I hate it. For certain people, it clicks, YES that’s what I needed. They can be very evangelical after. And then there’s a lot of people who do not click at all.

What ails the most the adults that you see?

It’s anxiety, by far. And that’s why I wrote Fragile. I really find that anxiety has completely overtaken… It used to be addictions, alcoholism, but now anxiety is pervasive. And that can manifest in panic, OCD, eating disorders, alcoholism, all of that can be rooted in anxiety. I’m nervous so I take a drink to relax. I’m nervous but my eating disorder is a dysfunctional coping mechanism to make me feel better. For secondary illness, generally, at root is anxiety. I really think that we’re asking too much of ourselves. We’re asking of ourselves so much more than our parents did, both from our homes and our work lives. Our homes are phenomenal! If any of us landed back into homes from 30 years ago… omg. The beauty of the kitchens, the bathrooms… I’m guilty of it too. Our homes are reflective of the high standards we’re living at. And I don’t think that high standards come without a price. And the price that we pay is, we are putting a hell of a lot effort into our lives. And that can make us very tense and anxious.

If you try to put 19 things into your day, you will end up failing and be very irritable when you fail. You won’t get them all in. When we had it simpler and traditional, we had a division of labour, one works, the other stays at home and takes care of the kids, and that appears now luxurious. I stay home and mind the kids, you go out to work, and yes it massively didn’t suit a lot of people, but on the other hand--and I’m not saying we should go back to it, I’m just saying--we are all working at a very high level. And we’re feeling more anxious than probably ever. We’re going very fast, and we’re cracking.

And we’re re-examining, turning everything over, wanting everything to be based on an informed choice, rather than, say, tradition. But there is no turning back to the word of before, I don’t think.

I don’t think so either. We use the phrase “the burden of choice”, “the burden of privilege”… I think it’s a very mental burden. It’s all in the mind. We could reduce our standards, and do less. And yes consumerism is driving a lot of our extraordinary standards. We won’t go back, but there’s a lot of backlash happening: slow food movement, slow parenting movement, the 4-day week movement, the right not to answer email after work hours, and I’m on my knees with thanks. I really think we need it. We should be able to say, I won’t be able to attend to that. I’ll do that tomorrow. This abuse by email! “I emailed you yesterday, you haven’t replied!” etc.

And there are of course some regressive responses to this, the Trad Wives, for example. The millennial and Gen-Z women who don’t want to work, and prefer to focus on raising children.

I do find when I talk to adolescents they say I’m not going to have the life that my mother had. No way. She’s working way too hard. She’s too tense. I’m not going to have that. It’s interesting that they do think that. I wish they were saying “I’m not going to have the life that my parents have, that doesn’t make sense to me”, but it’s mothers so is that straight up women blaming? But I honestly think that if it was possible to have one-income family when you have kids, it would be fabulous. Or, two people working part-time: that would be great. That’s why I’m interested in the 4-day week. If both of us are working part-time, then there’s the real feeling of, yes the kids are centered in this situation but I also do get to have a life. But yeah, it’s tricky.

As I’ve been complaining to everyone who would listen, I think friendship is in decline in North America. There’s absolutely no time or interest for new people in your life after a certain cut-off age. I think Europe is a little better in this regard?

It is, but we’re following the American model, and we’re following it fast. You’re right about friendship. So often I’d meet really lovely clients, and ask them, So where are your friends in this, they’d be like, I’m looking after my aging parents, I’m looking after children, I am working full-time, I have annoying in-laws that I see every Sunday, my neighbour next door who I stay friendly with but frankly don’t like very much, and there’s my sister who does my head in but I ring her regularly – and I never see my friend who I think the world of and can tell anything. And I say, Why don’t you? Well, I haven’t seen her in 3 months and I can’t just ring her up and just vomit everything down the phone. And that’s what happens. If you don’t tend to it regularly, your friendship goes a little bit colder, a little bit colder, and suddenly you’re in trouble-land. “I haven’t rung her in ages and I have so much to tell her, it’s too much—because I didn’t do the regular check-ins.” This is what happens in friendships. I remember reading the Top Five Regrets of the Dying, written by hospice nurse Bronnie Ware. She noticed there are themes with people who are dying and one was I wish I stayed in touch with my friends. And I think that’s really an issue. Especially my age group, I’m 47. We’re allowing our friendships to disappear because we need to have a career, a family, kids, and we don’t have space.

Stella O’Malley

II.

I wanted to ask you about the ‘anti-conversion therapy’ bills that are being introduced in many countries. I worry that they are going to outlaw basically—therapy.

There’s a lot of heightened emotion around everything to do with the LGBTQ world. The culture mores have started to shape the medical treatment and that’s an interesting development; I don’t think anybody saw it coming. So for example in Ireland where I’m based, they did a scoping survey, with much razzle dazzle, in order to find all the conversion therapists and they found that in the last 20 years, in Ireland and Europe, there was no conversion therapy. So all that attention and effort, to say, there is none. But they also said, we don’t know what we don’t know--we don’t know what we didn’t find. Although I’m sure conversion therapy is being practiced, in America especially, it was searched for in Ireland and they didn’t find it. The only place where it would be happening would be religious zealots trying to convert people out of homosexuality. And this is not therapy; it’s nothing to do with therapy. These are not therapists.

When activists attack me, I reiterate: I don’t deal with any sort of therapy that would have an outcome in mind. My job is an exploration process; let’s go where the person wants me to go and let’s explore it in depth. That’s what I offer.

There’s this big conflation within this term. We all have a fairly good idea what conversion therapy for being gay or lesbian is like. But some activists want us to believe that not immediately affirming cross-sex identification, what they call someone’s “inner gender identity”, and not immediately steering people on to a medical path -- is conversion therapy. I find this so brilliantly manipulative. Do you talk to your colleagues about this, do you ever feel under siege by the twitter warriors?

Yes. I do. And I don’t know why they would want to do that. Because I honestly want the best outcome for anybody who’s in gender distress. I think they are harming people like myself who genuinely want to give good, ethical treatment. And for some reason it’s been contorted. There’s a huge level of distrust. I tell them, go read tens of thousands of words that I wrote, the hundreds of hours of podcasts, I work really hard in this world trying to help so that the best outcome possible would be achieved. With a compassionate and curious mind. That’s what you need to bring into a therapeutic setting.

I don’t know… I think some people conflate being gay with being trans. That’s a big issue. And I think some gay people are presuming because they had some weird experience with some religious zealot maybe 30 years ago, that this is happening again. And I ask them, go and find me it. Where is it happening. I’ve only heard it happening in a deeply religious setting. No therapist does that.

It’s a really wrongheaded fight, to focus on exploratory psychotherapy. There is so much distress in the world, so many people need help. And to focus on bringing down people who are trying to help: it’s unnecessary, and saddening. I don’t know what’ll happen in the future. It is quite bruising.

UK had a case of activist journalism recently, where somebody recorded a pre-session -- during which therapists usually ask a few probing question and try to determine whether they’d be a good match for the client -- and publicized it as “attempt at conversion therapy”. This journalist was previously fishing around for leads of this kind, so that he could take down a therapist.

There were some activists who seem to really have an extraordinary level of malevolence towards certain people, and they had a list saying Have you had any therapy with, and named me, and Dr Az Hakeem and Marcus Evans. After this big campaign no one came out to say I had conversion therapy, but one person said I had a pre-therapeutic session, we’ll get him on that. Effectively, anybody can make a complaint. People can make up that they had therapy. What this journalist did was quite dishonest: he reported on the complaint. Once the General Medical Council saw the complaint, they threw it out. But he tried to tarnish Dr Hakeem’s name by reporting on the complaint only. Which, turns out, didn’t pass muster.

They sent in the complaint; the journalist went mad reporting on it; GMC looked at the complaint and said no; the end. But the damage was done by the journalist. It’s frightening for therapists. For example, I work with GenSpect, an organization that is trying to bring a rational voice to gender. And we have this huge new initiative Beyond Transition, where we want to help people who detransitioned, who weren’t happy with their medical transition. We’re launching that at the moment. We want to fund therapists to work with these detransitioners. Yet we know that there are so many therapists who are afraid to work in this field. There’s a chilling effect. And I’d often hear them say, there’s no work in this field, but there’s actually loads. If I wanted to, I could fill my list for the next ten years, today. I closed my wait list and you can’t work too much, but it’s unbelievable that so many therapists want to work in this field and they are afraid.

And we all know what happened in my own town, here, with Dr Zucker. Probably the most ignominious case yet of activism vs. psychotherapy.

He’s been working in gender for 40 years, one of the most published researchers in this area of study. Really knows his stuff; extraordinary mind, and always has a really comprehensive analysis of gender. When they attacked him in 2015, they struck fear into therapists all over the world. Because if Ken Zucker, Mr Gender, THE eminent researcher--if he can get sacked, can you imagine? I did a documentary in 2018, “Trans Kids, Let’s Talk” and I was asking at one point, What’s this story about this Ken Zucker guy, and they said, you can’t talk about it. He was struck off, there are probably issues there. And two weeks before the film went out, Ken Zucker was exonerated, and was rewarded more than half a million dollars in compensation. But the impact of that attack was unbelievable.

One final thing: I’m such a fan of your and Sasha Ayad’s podcast. Can you reveal what you’re preparing for the new season?

We have some really good plans. We’re going to interview some of the greats from Britain. It’s interesting what happened in Britain in the last few years around gender. The fight they fought. They seem to be a canary in the coalmine for many—and for a range of reasons. In my Irish eyes, there’s long-standing tradition of women’s activism in England, like the suffragettes. And there’s some sort of historical legacy that came to the fore when it was needed. I think it was extraordinary what happened. So we’re going to be interviewing a range of them. And I think we’ll have a “trans widow” guest in one show. We have a few other interviews lined up where we’re hoping to explore all the psychological shapes around gender. We started about 1.5 years ago and we have years left of things to talk about still, we feel.

It’s lovely that you have people you disagree with, therapists from completely different schools of thought on gender. And you just have a conversation.

I’m hoping to get more of that. We’d get into the controversial stuff and discuss it in good faith. Not trying to gotcha, but to figure out where are you coming from, and show where we’re coming from, and then see where it all goes. I’d love that.

Maybe we’ll see one of those therapists who are immediately affirming as one of your guests.

It’s funny, I’ve met with a group recently and their policy is to immediately affirm. They said, So what is this that you do Stella, and I say, I explore, nothing extraordinary. And they tell me, you know when they’re 13 or 14, they know their own mind. And I said, well I wouldn’t let them pick their college courses at that age. And they were like, Oh right…

June 10, 2022