EMDR Therapy Quarterly

Words have energy and power with the ability to help, to heal, to hinder, to hurt, to harm, to humiliate and to humble.

Yehuda Berg

Introduction

As healthcare professionals or psychotherapists, no matter our specific titles, we know how deeply the human psyche can be affected not by just actions but also words. Words carry power – the power to uplift, to connect, to heal, yet they also carry the potential to harm, divide and create invisible walls between practitioners and clients. This article aims to explore how inclusive language plays a pivotal role in building trust and effectiveness in therapeutic relationships, particularly for marginalised groups, such as the transgender community or those from other social minority groups.

Language can help us set the foundation for healing and resilience through providing a safe and respectful environment, and it is well documented as an important component of trust and rapport in the therapeutic encounter (Koch et al., 2023; Sharkiya, 2023). So, let’s dive deeper into how we can elevate a client’s experience through inclusive language.

When a client walks through the door, they bring with them not only their physical presence but their story, identity and experiences. There may be some overt indications that give us some insight into their story, but the vast majority of what makes our clients who they are is hidden behind an often carefully curated set of social masks, shaped by past experiences, cultural norms and personal defences.

The words we use to acknowledge and engage with them can either validate or alienate those experiences. We use language for more than just a tool for communicating – it reflects how we see the world and the individuals within it, and we use words to reflect to our clients our understanding of what they have shared. In a healthcare setting, words are foundational to building a strong therapeutic relationship through showing empathy, offering support and establishing trust.

Inclusive language: A nice to have or a must-do?

We might think that simply communicating and communicating well is good enough, but the reality is that clients who don’t feel heard in a consultation or therapy session and aren’t communicated with in an inclusive manner are unlikely to share all pertinent medical information with us. Why would they? For many members of social minority groups, feeling unsafe is a fact of life, and this lack of connection with healthcare professionals can have a profound impact on their care outcomes, hindering the effectiveness of therapeutic intervention and posing a very real risk to that patient.

Consider a transmasculine client seeking therapy for anxiety and depression. He doesn’t disclose his gender identity to the therapist for fear of being misunderstood, judged or invalidated. The therapist mistakenly uses incorrect pronouns during the first consultation, which reinforces the client’s decision not to share his trans identity. The therapist in turn fails to appreciate the impact societal stress related to his gender identity is having on him.

The repercussions are obvious. A therapeutic mismatch. A lack of awareness of key sources of his anxiety and depression. Inappropriate signposting or support. Missed opportunities to integrate medical care referrals for physical health needs such as hormone therapy. A breakdown in patient-provider trust which may reduce adherence to treatment and exacerbate mental health conditions.

Think instead, if inclusive language had been the golden thread throughout this interaction. What would the outcome have been if the therapist had asked the client for their pronouns, as is now considered standard practice in every client interaction? This awareness and acceptance of inclusive language opens doors to communication and trust, giving clients the confidence that they are seen and respected. This is especially true for those who have historically faced discrimination, such as members of the LGBTQIA+ community, who may already enter healthcare spaces with trepidation.

Building understanding of inclusive language

Inclusive language begins with the recognition that each individual is the expert on their own identity. It’s about being conscious of the words we use and how they reflect our respect – or lack thereof – for that individual’s lived experience. In practice, this means being mindful of gender pronouns, using person-first language instead of identity-first language (e.g., saying “a person with a disability” rather than “a disabled person”), and refraining from assumptions based on outward appearances. Additionally, it requires recognising the complexities of human identity and being aware of our own biases and assumptions.

It is never comfortable. The way we communicate, the assumptions we make, and the societal norms we ascribe to are often so deeply ingrained in our identities that altering these communication habits can be challenging. Yet, in an increasingly diverse society, adapting our language is essential. For instance, in discussions around maternity versus perinatal care, it’s crucial to recognise that not all individuals who give birth identify as mothers, and some may prefer terms that are more inclusive of all genders involved in the birthing process, such as ‘birthing parent.’ Similarly, when working with Deaf individuals, we should be using culturally appropriate language that respects their identity – such as capitalising ‘Deaf’ to denote a shared cultural identity and community.

Studies have shown that when patients feel respected and understood, they are more likely to engage in open communication, adhere to treatment plans, and experience positive health outcomes. For example, a 2015 study published in the Journal of General Internal Medicine found that transgender individuals who experienced affirming care – where healthcare providers used correct names and pronouns – were more likely to report positive emotional and physical health outcomes(White Hughto et al., 2015). It’s hard to argue against the need for inclusive language when it is so clearly linked with therapeutic benefits.

In contrast, when individuals feel invalidated by non-inclusive or discriminatory language, it creates barriers to care. Clients who feel they must repeatedly explain or defend their identity may disengage from therapy, lose trust in their practitioner or avoid seeking care altogether. This is particularly harmful to individuals who already face higher rates of mental health challenges due to societal marginalisation, such as transgender or gender non-binary individuals, as well as those from Deaf communities or individuals seeking perinatal support. The emotional toll of feeling unheard or misunderstood can exacerbate existing challenges, which can only ultimately hinder their recovery and overall health and well-being.

The impact of microaggressions

The term ‘microaggression’ was first coined by psychiatrist Dr Chester M. Pierce in 1970 to describe the subtle, often unintentional, forms of discrimination faced by marginalised groups. Microaggressions are everyday slights, insults or negative messages – whether verbal or behavioural – that can contribute to a hostile or unwelcoming environment. In healthcare, these can manifest as seemingly innocuous comments or assumptions that dismiss a patient’s identity or experiences. Think back to the beginning of this piece, where we talked about the masks our clients hide behind – by assuming someone’s abilities or preferences are visible in their appearance or background, we are making a micro assumption. When expressed, this can contribute to feelings of exclusion or invalidation for the individual on the receiving end.

Microaggressions can be loosely categorised into micro assaults (“Why do you women always get so emotional in meetings?”), microinvalidations (“I don’t see colour, I treat all my patients the same!”), and micro insults (“But you don’t look gay!”). Though often unintentional, microaggressions such as these can have a profound effect on the therapeutic relationship, contributing to feelings of shame, frustration and distress. That’s not all – microaggressions are closely linked to stress and trauma, and for individuals who regularly experience microaggressions, this can lead to a host of negative health outcomes. Chronic exposure to microaggressions can elevate stress hormones, resulting in anxiety, depression, and physical health issues such as cardiovascular disease. Research also indicates that patients who face frequent microaggressions may experience a diminished sense of belonging and increased psychological distress, which further exacerbates health disparities within marginalised communities. This is where building our understanding of inclusive language and taking the time to learn more about the language pitfalls we may be falling foul of can help eradicate these more subtle forms of bias.

Using transgender-inclusive language in practice

Non-inclusive language is woven throughout the very fabric of how many of us communicate, and our first tentative steps into changing this will always feel fumbling and awkward. To stop saying “hey guys” when you walk into a room of people or avoid referring to your family as your ‘tribe’. The former is gendered language, which excludes members of the LGBTQIA+ community, and the latter misappropriates Indigenous culture.

As a cisgender, gay woman, I’ll focus on gender and sexuality inclusive language, as I recognise and acknowledge that individuals from other minority groups are better positioned to speak to their own lived experiences.

When it comes to LGBTQIA+-inclusive language, specificity is key. This means not only using the correct pronouns and names but also being aware of how language can affirm or negate an individual’s gender identity. It’s essential that, as healthcare providers, we educate ourselves on the experiences and needs of transgender individuals rather than relying on them to correct our language or explain their identities.

One powerful tool for creating an inclusive environment is simply asking our clients the questions we need answers to, directly, and without any degree of awkwardness. At the beginning of a session, ask your clients which pronouns they use. No, not ‘preferred’ pronouns – it’s not a preference or an option. Then make a note of them somewhere obvious – the front of their file or the top of your page of notes. It’s a small yet profound act of respect to help clients feel safe and seen. It’s understandable if this all seems a little baffling – many practitioners may not have encountered this practice before or may feel uncertain about approaching it, and neopronouns are often associated with being ‘woke’. Being woke is all about recognising and respecting identities, and using neopronouns correctly is no different from learning how to say someone’s name correctly. The world is changing, language is changing, and embracing neopronouns ensures that the healthcare profession keeps pace with the population that we serve.

Being woke is all about recognising and respecting identities.

Actively engaging with our clients about their identities is a powerful way to strengthen the therapeutic alliance. Using correct names and pronouns is linked with improved health outcomes and reduced feelings of alienation amongst LGBTQ+ individuals. Research indicates that using correct names and pronouns can improve mental health outcomes and reduce feelings of alienation among LGBTQ+ individuals (Budge et al., 2013; McLemore, 2018). When we understand and know how to use neopronouns, and make an effort to use more inclusive language, we not only validate their identities, but also contribute to a more inclusive and supportive healthcare environment.

And it’s not just about pronouns. Transgender and gender nonbinary individuals face a host of unique challenges in healthcare settings, from having their medical histories pathologised to dealing with providers who are unfamiliar with their specific health needs. In the same way we would educate ourselves about a new condition or new treatment guideline, so we must also educate ourselves about the words we use, their impact and be prepared to confront our own biases in order to provide the highest standard of care. This means staying informed about issues such as gender-affirming hormone therapy, the emotional toll of transitioning and the societal pressures faced by transgender individuals.

It can feel like navigating a minefield. As we move beyond just talking about ‘gay men’ to including terms like ‘men who have sex with men,’ and as identities shift – someone may identify as pansexual one week and asexual the next – it can be challenging to keep up. The term ‘queer’ is being reclaimed by the LGBTQIA+ community, even though many of us may have grown up seeing it as derogatory. This constant evolution makes it difficult to know how to approach these conversations, how to manage them practically in a clinical setting, and – perhaps the most frequent question I’m asked – what do I do if I make a mistake?

It’s quite simple. Apologise, briefly and succinctly. If you recognise it in the moment, you could restate your sentence with the correct term. The key here is to avoid making your mistake the focus of the conversation, which often simply serves to prolong someone’s discomfort.

It would be comforting to think that many of us do not intentionally misgender people, and yet are we all proactive in preventing mistakes and minimising the damage the words of others could inflict? If someone around you makes a mistake, a simple correction can suffice. If it continues to happen, you may need to be firmer. “Jemma is a woman, and you should use she/her pronouns when you refer to her, please.” This takes you beyond the realms of allyship and into advocacy, and your clients will thank you for it.

The path forward: Educating ourselves and others

We have the privilege and the responsibility to shape the experiences of our clients.

As healthcare providers, we are tasked with keeping abreast of the changing world of language and identity. This means not just learning about inclusive language but also understanding the experiences of marginalised communities. Making cultural competence and LGBTQ+ inclusion a regular part of our professional development helps us better meet the needs of all our patients. We must understand that language is not neutral. It is a tool that can either open the door to healing or shut it.

We also have a shared responsibility to drive systemic change. From private practices to the NHS, everyone needs to prioritise inclusive language and create policies that back it up. This could mean providing training on transgender issues, updating intake forms to include gender-neutral options and implementing procedures that affirm everyone’s identity.

At the core of all this is a simple yet powerful truth: words can hurt, but they can also heal. By being mindful of our language, we can build environments where clients feel safe, respected and supported. In doing so, we not only do our job as healthcare providers but also help create a more just and compassionate world.

We have the privilege and the responsibility to shape the experiences of our clients. By embracing inclusive language, we pave the way for deeper connections and more meaningful therapeutic work. The words we choose matter – so let’s choose them wisely, with care, empathy and intention. After all, in our hands, words have the power to heal.

Philippa Oakley (she/her) is a qualified chiropractor and coach with an international reputation for her pioneering work in providing inclusive care for the LGBTQ+ community. With over 12 years of clinical experience in both the NHS and private practice, Philippa has dedicated her career to improving patient care and outcomes through effective communication and inclusive healthcare. www.acornhealth.org.uk