Her discomfort with her birth-assigned gender had felt like an impediment to forming friendships, finding a partner, and engaging with the world in an authentic and meaningful way. Now that the condition had been removed, Kim wondered how to realize these other desires and goals. Questions 1. The case references the sense on the part of Kim’s family that they have suffered a loss and that things have changed. 2. How might this formulation - Kim’s transition precipitated losses - be similar or different from Kim’s experience? 3. How can Kim’s experience of coming out help us understand her relational experiences with her family? How might this inform our understanding of Kim’s presenting concerns? 4. Kim describes a tension between her family’s religion and gender identity. What might be helpful to Kim in addressing this tension? 5. Are there other culturally salient matters? If so, how would you begin to talk with Kim about these matters? 6. Kim expressed some fear and revulsion at associating with other transgender people; how would you address this and work with Kim around this? 7. How might you conceptualize her original depression? How might this be impacted by issues related to gender identity? What does the reappearance of her depression during the transition indicate? Discussion This case suggests another important feature of working with transgender clients: Clients come to therapy for many things that have little to do with their gender. This client wants to focus on themes of intimacy and relationships. These issues cannot be fully understood without attention to Alice’s experiences with gender and being known or unknown by others. Still, these concerns are not the focus Case Study 10: Ana Ana was a 20-year-old, heterosexual, Croatian American female in her sophomore year at a predominantly White university in the eastern U.S. She appeared older than her stated age and was dressed in fashionable clothing with neat, long, straight hair. She presents for counseling for assistance with depression and suicidal ideation after the breakup of a one-year-long romantic relationship. However, her affect was restricted, revealing no evidence of depressed feelings. Ana tearfully reported that she was at fault for the breakup, as her boyfriend walked off after she had angrily lashed out at him for rejecting her. Ana grew up in one of the poorest communities in the south-central U.S. She was the only child of a single immigrant mother whose financial struggles led to numerous evictions, blackouts due to unpaid electric bills, and limited healthcare or childcare. Ana’s mother also worked as an overnight security guard. For that reason, Ana was often left unattended or with relatives or family friends. By the time Ana was seven years old, she had learned to care for herself by walking home from school alone and cooking her meals. Her psychiatric history included two hospitalizations associated with suicide attempts and deliberate self-harm, the first occurring when she was 16. During her second hospitalization, at 18 years old, Ana was diagnosed with a borderline personality disorder, at which point her mother reprimanded her harshly for being “weak-minded.” Ana expressed anger toward her mother, describing her as a “bad parent”; Ana’s mother rejected her daughter by sending Ana to live with her grandmother after the first hospitalization. At the same time, Ana understood her
of the treatment. Transgender individuals are not immune to society’s messages about gender and often struggle with internalized transphobia, as evident in Kim’s avoidance of other transgender people in support groups. These feelings can emerge in clients’ feelings about their bodies as they transition and intensify the social isolation many transgender people feel. Although this client yearns for connection with people who understand her, she is ambivalent about being associated with other “freaks.” Working to understand her feelings while also helping her develop empathy and appreciation for herself and other transgender people became an essential aspect of the work. Some transgender individuals will present with a history of mental health issues. Many people experience a lessening or disappearance of symptoms when they internalize their gender identity and begin their transition, much like this client. Many people often find that their mental health issues return, as Kim’s depression did, once they experience some difficulties related to the physical and social transition. A therapist should be cautious about interpreting this to mean that the change is not healthy for the client or that the client is not it for surgery. It is essential to consider that Kim’s depression emerged as her transition impacted her social relationships and how society perceived her. It seems possible that her depression was related to the stress from prejudice and discrimination, being misread by others, fear of transphobia, and her family’s reaction. Thus, the conceptualization of transgender individuals’ symptoms must include understanding the influence of the external environment(s) on internal experiences (mood, sense of self, for example). Including societal impact in one’s conceptualization of the presenting concern does not necessarily mean this will be the focus of treatment (Sue et al., 2013). mother’s decision to send her to live with her grandmother. Ana believed that her mother had “enough on her plate” and could not also care for a daughter with a mental illness. Her grandmother, in contrast, had cared for more than 25 foster children in the past 10 years, so her mother saw her grandmother as someone who could deal with problem behavior. Ana reported that her grandmother’s fostering of children was not due to a love for children but because the funding she received as a foster parent gave her the financial means to care for her own four children. Ana said that she wanted to learn skills to communicate more effectively with her romantic partners. Ana was adamant that she was not like other poor people, and she spoke confidently of her experiences as a high-achieving student. Ana wondered whether she was good enough for this young man, whether she spoke, dressed, or acted sufficiently well for him. Ana felt that it was useless to sit with or explore her feelings. She presents as guarded, withdrawn, tense, and avoiding eye contact. Ana states that she feels hopeless. Questions 1. What is the role of socioeconomic status/poverty in the client’s presenting problem? 2. How does the client’s social class status directly and indirectly affect her presenting concern and her ability to heal from it? 3. Do you think the diagnosis of borderline personality disorder applies to Ana?
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