An Open Letter to Therapists: The Harm of Affirmation
By Evelyn Ball
“It is a joy to be hidden, and a disaster not to be found.” – D.W. Winnicott
Dear Colleagues,
The recent Washington Post advice column, Ask Sahaj: ‘Heartbroken’ mom doesn’t believe her adult kid is trans, offered a striking example of how therapy collapses when the focus is on affirmation — the search is over before it has even begun.
In a letter asking for help, a distraught mother described her daughter, once a high-achieving student with plans of becoming a doctor since childhood:
“In her sophomore year, she began struggling with classes and lost her scholarship… She began identifying as male… had a mental breakdown in the first semester of senior year and dropped out of school… [She and her partner] have hopped between several low-wage jobs, went on Medicaid (my daughter has T1 diabetes)… They defaulted on their lease… They have no jobs, no money, and no plans… I’ve offered for my daughter to come home and live rent-free… My daughter has become an entirely different person… How can we improve her situation?”
Therapist-columnist, Sahaj Kaur Kohli’s response?
“… your son is becoming who he has always been and is now feeling confident enough to emerge more fully as himself… Use your child’s pronouns and name; after all, it’s the foundation for the bridge that keeps you in his life… you are also not showing up as a safe or supportive place for him to lean on… from where I’m sitting, your worrying is actually more about your desire for control…”
Notice what happened? The daughter’s unraveling—academic collapse, financial instability, medical neglect—was reframed as “emergence.” The mother’s knowledge of her daughter was dismissed, and her deep concern for her child’s welfare was pathologized as control. The broader crisis was erased.
This is affirmation in practice: it silences curiosity about what suffering and dysregulation might mean.
When Therapy Affirms
As therapists, we know what it means to validate suffering. Validation says: “Yes, I see you. I see that this is how it feels right now, and it matters.” That simple act removes shame and creates safety. It opens the door to curiosity. And once curiosity is alive, we can begin to ask: Where did this feeling come from? What shaped it? What might it be protecting?
Affirmation, by contrast, closes the door. It says: “Yes, this is who you are. Case closed.” It mirrors the presentation while leaving the depths untouched.
Imagine if, in response to a client describing agoraphobic behavior—unable to leave their home for months, completely reliant on others to perform all errands— a therapist affirmed their “indoor identity” as their true self, rather than exploring what it signals: grief, trauma, unmet needs.
We would denounce that. And yet, when it comes to gender, all discernment seems to vanish.
The Cost of Collapsing into Scripts
Because therapy is demanding, we must protect its integrity. The stakes are uniquely high with identity-questioning teens and young adults. Affirmation enables psychological self-harm, colluding with a person’s shame and fragility. It neither challenges nor builds the strength, maturity, and resilience needed for real growth.
Working with support groups in Beyond Trans, I meet many individuals who deeply regret their transition, and whose therapy stories echo the same crippling theme: their confusion was met not with the care of exploration but with the ease of affirmation. Therapists quickly communicated a single treatment protocol. Many were encouraged to lean further into opposite sex personas, pressured toward puberty blockers, hormones, and irreparable surgeries, or told to “do whatever you want.” One older adult described himself as “living in the shadows.”
Years later, they grieve the absence of truly being seen. They describe despair at the lack of care shown by professionals in our field—the gaps in identifying the role of sexual abuse or internalized homophobia, the blindness to unmet attachment and developmental needs, the failure to bring curiosity and courage to the therapeutic relationship.
Affirmation may look like kindness. But in practice, it abandons children, vulnerable adults, and parents alike—to despair. When therapy collapses into affirmation, suffering is ignored, development is derailed, and trust in our profession is betrayed.
The Meaning in Chaos
Early Saturday morning, I awoke to a deep restlessness. Paying close attention, its shape materialized: a block of chaos in my chest, rigid and uneasy. I breathed. I surrendered to its presence and allowed it to communicate.
Its message was unmistakable: this chaos is not just mine, and it’s not just now. It runs underneath and between us all—our clients, our families, ourselves. This unease is the product of a culture that confuses identity with constant performance, leaving us too often anxious, unmoored, and searching for solid ground.
This is why careful inquiry matters: chaos carries meaning, and with our clients we must trace its threads, not embrace it as identity. To simply nod our way through sessions is to ignore what’s most urgent.
The Cultural Tide Within the Profession
Colleagues, our clients need us to resist the cultural tide rebranding affirmation as care. Therapy isn’t about siding with one narrative; it’s about opening the door to the meaning it holds.
This tide is strong: Major bodies like the AMA, AAP, and APA now deem “gender-affirming care” medically necessary and “affirmation-only” best practice. Yet, attuning to vulnerable, questioning clients—their turmoil, trauma, and inner dialogue—reveals layers no single script can capture.
Following that script isn’t neutral. It propels children toward social confusion, body disconnection, activist immersion, and interventions that stunt healthy development—a path of irreversible change they can’t yet fathom, because they haven’t been allowed to grow.
Let’s show up as principled professionals: Give youth the space to build resilience for truly rich lives. Attune, don’t echo. Explore, not collude. Otherwise, we risk leaving our clients hidden in plain sight.
With Care,
Evelyn
A licensed psychotherapist and writer, Evelyn Ball helps families, adolescents, and adults explore identity, build resilience, and foster authentic connection. More of her work can be found on Substack at Evelyn Ball.
Photo by Dmitry Ratushny on Unsplash
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