Behavioral Approach and Progress Monitoring
In therapy, a strong emphasis is placed on being behavioral, meaning that progress needs to be measurable. For Ava, her goal was to start transitioning, and this meant taking concrete steps such as getting connected with a voice therapist, learning about gender-affirming hormones (specifically estrogen) and disclosing her gender identity to more people. The therapy approach involved setting SMART goals—specific, measurable, achievable, relevant, and timely objectives to ensure these goals were clear and attainable.
One key aspect of Ava’s therapy involved setting daily goals, such as practicing voice training for 30 minutes. Ava monitored her progress by tracking how many days she accomplished this, bringing the results to each session. Regular tracking allowed for greater accountability and mindfulness of her progress. This process also helped keep Ava focused and moving forward in her transition.
Managing Discomfort in Voice Training
For many individuals, including Ava, voice training can trigger dysphoria. The discrepancy between how one sounds and how one wishes to sound—especially in relation to one’s gender identity—can be a source of anxiety, embarrassment, and discomfort. However, therapy became a safe space where Ava could practice her feminine voice, even though it felt awkward and anxiety-provoking at times. Through gradual exposure and committed action, she was able to confront these feelings and make meaningful progress in transitioning.
Addressing Worry and Changing Language
Ava experienced significant anxiety and worry, particularly about making phone calls to medical providers. She found herself hesitating for long periods before making calls, often worrying that she would say something wrong or inconvenience the provider. Her racing thoughts and elevated heart rate made the task seem overwhelming, leading her to avoid it altogether.
In therapy, attention was drawn to how language can reinforce avoidance. For example, when Ava said, “I can’t make this phone call” or “I’m too anxious to transition,” she was reinforcing the idea that these tasks were impossible. The goal in ACT is to reframe this language in a way that offers choice and accountability. Instead of “I can’t make this phone call,” she was encouraged to say, “I want to make this phone call, and I’m anxious about it.” By changing the narrative from “but” to “and,” Ava could acknowledge her anxiety while still taking committed action.
ACT does not focus on whether a thought is true or false but on whether it helps move toward one’s values. Ava learned that she could have thoughts of worry or embarrassment and still make the phone call if it was important enough to her. This shift in perspective allowed her to approach challenges with greater flexibility and purpose.