Assessment and Treatment of Gender Identity Disorder (GID) {Part 1} Wednesday, Oct 20 2010 

Sexual Challenge Chosen

 

When it came to making a decision for a sexual challenge, there was not a hard choice on what we would like to choose. Since I have an in depth study in regards to transgender studies in psychology for the last two years, I felt that this would be our best choice to consider. Along with this particular challenge, we also received homosexuality and transvestite as part of our research. As the challenge was more understood, new insight was understood about both of these additional issues.

The first concern that came up was in regards to homosexuality and how it is not a sexual challenge, per se, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Version, Text Revision (DSM IV-TR). Since its removal in 1973, homosexuality has been a challenge only in light of how it affects the individual and not as a mental health disorder. The second concern we had was in regards to transvestites. With very little information written in regards to transvestites, or Transvestic Fetishism as it known in the DSM IV-TR, we decided that it would be more profitable to discuss transgender more in depth as this paper’s sexual challenge.

History of Gender Identity Disorder

Transgender has had an interesting and somewhat complex history both in and out of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The term “transgender” only came to be in the late twentieth century; however, the precise time of when this term came to be established is unclear. It appears that the histories of the transgender individuals, specifically transsexuals and transvestites, are scantly documented prior to the twentieth century.  Many of the transgender population have rejected even the label “transvestite” because the term “invokes concepts of psychological pathology, sexual fetishism, and obsession, when there is really nothing at all unhealthy about this form of self-expression” (Feinberg, 1996, Riddle-Crilly, 2009).

 The second term in this category is “transsexualism” (or transsexual), and it was coined by Harry Benjamin MD in 1953. Research indicates that Dr. Benjamin is often attributed as being the ‘father of transsexualism’ (as cited in Clarke & Peel, 2007). It was 26 years later in 1979 that Dr. Harry Benjamin published his first Standards of Care, which is now in its sixth edition.  It has been revised to DSM standards as well, known most commonly as the Standards of Care for Gender Identity Disorders. This document is used to understand the parameters within which professionals may offer assistance to those with gender identity issues (WPATH & HBIGDA, 2010).

The final term in the series for transgender studies is the term “transvestite” or “transvestism. The term transvestism was coined by Magnus Hirschfeld MD, a physician, sexologist, and gay rights pioneer (Unknown, 2010), who in 1910 presented this new term that referred to individuals who cross-dressed during his time. This included but was not limited to individuals who identified as drag-queens or drag-kings, transvestites, transsexuals, female illusionists or impersonators (even though many of these terms were not presented for many years later) as well as some “psychotic” individuals who believed that they are members of the opposite sex (Bullough & Bullough, 1977; Moser & Kleinplatz, 2002). This term would become the beginning of a long list of terminology that would ultimately refer to individuals diagnosed with gender identity disorder.

The history of transgender, transsexual, or gender identity disorder has been a roller coaster ride for transgender individuals when it comes to the DSM. In the DSM-I for instance, the term “transgender” did not exist, and the term “transsexualism” had not been identified until a year after the DSM-I had been published (American Psychiatric Association, 1952). In this version of the DSM, the American Psychiatric Association (APA) saw individuals who dressed in opposite sex clothing as “transvestism”, which was classified under Sexual Deviations. Ironically, this has not changed much in terms of societal perceptions, as many people still see transgender individuals as living a deviant lifestyle. In 1968, the APA continued their position that individuals

“…whose sexual interests are directed primarily toward objects other than people of the opposite sex, toward sexual acts not usually associated with coitus, or toward coitus performed under bizarre circumstances as in necrophilia, pedophilia, sexual sadism, and fetishism. Even though many find their practices distasteful, they remain unable to substitute normal sexual behavior for them. This diagnosis is not appropriate for individuals who perform deviant sexual acts because normal sexual objects are not available to them” (American Psychiatric Association, 1968).

It also included that these sexual deviations were diagnosed as mental disorders. It was at this time that the APA chose to call this disorder transvestitism instead of transvestism as it had in DSM-I.

            It was not until fifteen years later in the DSM-III that the APA chose to reclassify transvestitism into four classifications. Including the return of transvestism, the new identifiers were transsexualism, gender identity disorder of childhood, and atypical gender identity disorder (American Psychiatric Association, 1983). It was also during this new version of the DSM that the APA added many new sexual disorders under its new category of “Psychosexual” disorders. When the APA decided it was time for a revision of the DSM-III in the DSM-II-R, they changed the whole thinking of terminology when it came to the newly coined sexual disorders. Heterosexual males who had recurrent intense sexual urges and arousing fantasies involving cross-dressing would be recognized now as suffering from Transvestic Fetishism, which has remained the same in both the DSM-IV and the DSM-IV-TR.

            Although some things did change in the DSM-III-R (1987), others did not. Transsexualism, gender identity disorder of childhood remained in the new DSM; however, atypical gender identity disorder was no longer included and came to be replaced with gender identity disorder of adolescence or adulthood and gender identity disorder not otherwise specified. Sadly, this would not be the change gender variant individuals would be looking for, nor would the diagnostic criteria and diagnoses for individuals who felt that they were born in the wrong body. One other change that had taken place with gender identity disorder (GID) is that it had now been moved from being a sexual disorder to being a disorder usually first evident in infancy, childhood or adolescence.

            In 1994, the American Psychiatric Association felt it was once again time to revamp the DSM, and published the DSM-IV. It was at this time that the removal of transsexualism was considered a positive change and a path toward the right direction; it was also deemed as a “sexual, gender identity disorder type.” This seemed to be the major downfall to the change in the DSM-IV (1994) from the DSM-III-R according to various transgender organizations. With very little change in the DSM-IV-TR (2000) from the previous version, except for the fact that it is no longer included as a sexual disorder, many gender associations have been pushing for a change in the DSM V. According to the most recent reports, a change is coming that will tentatively alter both the name of the disorder as well as its listing in the DSM V (Sexual and Gender, 2010). In a previous research paper, which was completed in 2008, one author wrote,

…it is fortuitous that we as a society and as professionals be able to rehabilitate our thinking to support the betterment of life for the transgender individual by stopping and taking into consideration the damage that we are invoking on these individuals who are unable to simply “change their feelings” about being a transsexual.  By adjusting our conceptual … and changing our mentality to believe that in so doing we can be causing tremendous mental harm, it is the authors opinion that we as psychologists, sociologists, and psychiatrists, must find a way to dissolve the categorizing of transgenders and transsexuals as a disorder. I believe the APA needs to consider disassociating GID as a mental disorder from the DSM-V when released in 2012 (Riddle-Crilly, 2008). 

One additional interesting fact appeared in researching GID as a psychopathological disorder. In the research the author states,

With as many as 3.04 million individuals in the United States living with GID, whether diagnosed or not, it appears that this area needs to be highly addressed in regards of diagnosing people without setting a stigma on them.  Unfortunately, because of our societal norms, a stigma has been set on any mental disorder that we diagnose a patient with, and in an area such as Tulare County, where as many as 4,200 people, who again are or are not diagnosed with GID. Stigmas need to be addressed in order for these individuals to receive treatment as to not harm themselves, such as in the instance of Martina, who earlier this year took her life in Visalia because of the lack of assistance she was unable to find (Riddle-Crilly, 2010). 

The DSM Criteria for Diagnosis and the Sub Categories of the Disorder

In understanding what is involved in diagnosing GID, one needs to be aware of what is written as the current criteria of the DSM-IV-TR. This includes:

A.  A strong persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex). In children, the disturbance is manifested by four (or more) of the following:

  1. Repeatedly stated desire to be, or insistence that he or she is, the other sex.
  2. In boys, preference for cross-dressing or simulating female attire; In girls, insistence on wearing only stereotypical masculine clothing.
  3. Strong and persistent preferences for cross-sex roles in make believe play or persistent fantasies of being the other sex.
  4. Intense desire to participate in the stereotypical games and pastimes of the other sex.
  5. Strong preference for playmates of the other sex.

In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex.

B. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex.

In children, the disturbance is manifested by any of the following:
In boys, assertion that his penis or testes are disgusting or will disappear or assertion that it would be better not to have a penis, or aversion toward rough-and-tumble play and rejection of male stereotypical toys, games, and activities.
In girls, rejection of urinating in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate, or marked aversion toward normative feminine clothing.

In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex.

C. The disturbance is not concurrent with physical intersex condition.

D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Code based on current age:

  • 302.6 Gender Identity Disorder in Children
  • 302.85 Gender Identity Disorder in Adolescents or Adults

Specify if (for sexually mature individuals):

  • Sexually Attracted to Males
  • Sexually Attracted to Females
  • Sexually Attracted to Both
  • Sexually Attracted to Neither

Additionally:

302.6 Gender Identity Disorder Not Otherwise Specified

This category is included for coding disorders in gender identity that are not classifiable as a specific Gender Identity Disorder. Examples include:

  1. Intersex conditions (e.g., androgen insensitivity syndrome or congenital adrenal hyperplasia) and accompanying gender dysphoria
  2. Transient, stress-related cross-dressing behavior
  3. Persistent preoccupation with castration or penectomy without a desire to acquire the sex characteristics of the other sex

Part 2 is not included as this was written by another individual.

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Becoming a Gender Specialist: Issues in Assisting Transgender Individuals in Their Transitions Sunday, Aug 29 2010 

Abstract

Gender Specialists are trained professionals, paraprofessionals, or peer-support care providers who are trained to work with the transgender population in the mental health field.  These specialists need to understand not only the psychosocial and psychiatric aspects, but also the various steps, processes and issues (i.e. physical, medical, and economic) that arise for the transgender client.  It is important that not only Gender Specialists and transgender individuals understand the complete transition process, but every engaged mental health counselor that works with a transgender client needs to be aware of the progression as well.  Each step has procedures that need to take place; this includes the assessment process, pre-operative counseling, hormone therapy, the life-test, gender reassignment surgery, and post-operative care.  These are the key methods that the transgender client will go through in their transition development and according to the Harry Benjamin International Gender Dysphoria Association; they require the help of a counselor to attain nearly all of this process.

Introduction

With the emergence of numerous psychological concerns in therapy over the years, one may perhaps suggest that counseling the transgender individual is even more of a challenge than perhaps any other concern in this field of study.  In order to understand the transgender individual and their mental health requests, a therapist should not only concern themselves with the various matters that could arise in the counseling sessions, but they should conduct an in-depth assessment of who transgendered individual is as a human being and what concerns they may have with their identity.

To comprehend and appreciate the transgender individual, the therapist needs to recognize the semblance of the transgendered person not only through text on how to counsel them, but through individual accounts from transgendered persons.  With the amount of time given to complete this undertaking, some therapists may perhaps find it complex to recognize the nature of transgenderism in a short period of time.  As a result, therapists would probably need direction from specialists in the field of transgender counseling in addition to reading of various peer reviewed articles and texts.  With an assortment of issues that can present themselves throughout the path of an individual’s transition, the inexperienced therapist may find it easier to refer the client to a more qualified therapist in the field and then decide to gain the information needed in assisting such individuals.  With the evolution of medical science, it is no wonder that the field of psychology is seeing a rise of individuals needing the assistance of professionals in determining if complete gender reassignment surgery is appropriate for them or if a less radical procedure (e.g. only hormone treatment) would be in order.

Gordon Allport once said that “the goal of psychology is to reduce discord among our philosophies of man and to establish a scale of probable truth” (1955), and in one of his previous texts he relayed that “general psychology…selects a single attribute or function that can be conveniently isolated for study” (Allport, 1937).  By looking at underlying issues that the transgendered individual may be dealing with, we can see that the matter at hand most likely would not be transgenderism but could be any number of other factors.  William Wundt (1937) understood that psychology examines the complete content of experience in its associations to the subject.  Consequently with this consideration, we see that there is probably more to a clients yearning to transform their gender identity than just gender reassignment surgery; this can involve any number of mental health concerns.

There are various processes in the transition of a transgendered individual that take place, with each individual being as unique and individualistic as the non-transgender individual.  For transgendered individuals these processes include pre-operative psychotherapy, the assessment, hormone therapy, the commitment to a life change process, life skills training, gender reassignment surgery (or sex reassignment surgery), and post-operative psychotherapy, which includes the termination of the counseling process or the continuing counseling process.  It is through these processes that the transgendered person needs to make steps in order to discover themselves in their best state of being.  For that reason, it is no surprise that we see the need to counsel each of these individuals with a more open mind and complete understanding, to beware of our biases, and to be cautious and  aware of our own manifesting countertransference issues that could surface for even the most culturally sensitive and experienced therapist. 

The belief of who a transgender individual is, without looking at the subject matter from the psychological perspective, could easily consume a number of pages that would address various thoughts and ideas on the subject matter and would become increasingly inapplicable to the matter at hand. It is for this reason that the ideas that are to be presented here will be on the basis of counseling and the complete transition process of the transgendered individual.

 

Narrative

The transgender individual is more than what one thinks of when we talk about transsexuals.  The term transgender extends to include approximately 100 various sexual identities that include drag kings and drag queens, two-spirits, androgynous, intersexed, transgenderists, transvestites, and transsexuals, just to name a few (L. A. Sausa, Ph.D., personal communication, October 15, 2008; Transgender Glossary, 1994/2008).  It was during the late twentieth century that two pronouns were adopted as gender-neutral pronouns during this trans-liberation movement.  These two pronouns, ze or sie in place of she or he and hir in place of him or her (Feinberg, 1996; Stryker, 2008), have not taken hold in today’s cultures, and may not become prominent words in society for many years (1996). Many also “feel their gender identity to be that of a ‘third gender’” (Parlee, 1998), leaving some individuals wondering what pronoun should be used to refer to them in conversations.

The histories of the transgender individual, specifically the transsexual and transvestite, have little records, if any, prior to the twentieth century.  Even the label transvestite has been rejected by many of the transgender population because the term “invokes concepts of psychological pathology, sexual fetishism, and obsession, when there is really nothing at all unhealthy about this form of self-expression” (Feinberg, 1996).  Although there are several identities under the transgender umbrella, the transsexual has a strong mind-set of having erroneously been born in the wrong body, often from childhood onwards (Zhou, Hofman, Gooren, & Swaab, 1995).  Roger E. Peo (as cited in Emerson, 1996) once defined gender identity as one’s internal perception of one’s self as either a man or a woman and Shirley Emerson said that “in our culture, gender identity is assumed to be consistent with a person’s genetic sex (1996).

With years of being afraid to let people know about their feelings and desires, and the possibility of threats or even death, transsexuals have had to worry about being who they are.  It has only been in the last thirty to forty years that transgender’s have been coming out and letting people know who they are.  With coming out has come heartache, struggle and even the fear of becoming martyr’s for what they believed in.  To understand more about the transsexual and those included under the transgender umbrella we, as the non-transgender individuals, need to recognize the history and their stories.

In 1654, Christina, Queen of Sweden, chose to take on the name Count Dohna and dressed in men’s clothing.  This is the first known account of a female changing her name as well as her identity completely from female to male.  The earliest person in history known to change only her identity from female to male (FTM) was Joan of Arc when she believed that the Saints Catherine of Alexandria and Margaret of Antioch had spoken to her about helping to fight in the Hundred Year’s War in the late 1420’s and early 1430’s before her death (Riddle, 2008) The transsexual male to female (MFT) was first written about in Abbe Francois Timoleon de Choisy’s memoirs in 1676, when she attended a Papal inaugural ball in female dress (Transgender History, 2009).  Until this time in history there had been very little, if any manuscript, written about such things.  Much of this was most likely due to the societal taboo associated with the transgender identity over the last three or four thousand years (Hotchkiss, 1995).

During the late eighteen hundreds we read of instances of “crossing the gender border,” (Elkins & King, 2006).  When individuals were participating in this behavior, they were described in terms of ‘masquerade,’ ‘disguise,’ or ‘impersonation” (2006).  Even through the 1930’s, there were “masque” balls in cities such as New York, which followed the coined term of masquerade (Feinberg, 1996), and it was during these masque balls that one could be arrested for dressing “inappropriately” in the clothing of the opposite gender. 

The first time we are actually aware of any terminology for the transgender identities is in 1919 when Magnus Hirschfeld coined the term “transvestite,” (Brown, 1998/2007; Liv (Site Admin), 1999/2009).  The following year Jonathan Gilbert published a book entitled “Homosexuality and Its Treatment’ in which he tells of the story of Dr. Alan Hart’s FTM transition in 1917.  Eventually in 1931, Hirschfeld coined the new term “transsexual” (1999/2009).  Throughout the 1930’s and 1940’s advancements in the field of endocrinology were being made and 16 cases were reported to have some sort of gender surgery prior to 1953 (Feinberg, 2006).

Sadly, due to the ignorance and misguided individuals, transgender people have had to fight just to stay alive in many cases.  On November 14, 2008, in Syracuse, New York, a young MTF transgender named Lateisha Green was standing outside a house party when she was shot and killed.  Originally the killer shot her because he thought that Lateisha was gay.  With the Gender Expression Non-Discrimination Act awaiting in the New York state senate, it would make it a hate crime for someone to attack another person because of their gender or gender expression.  The Matthew Shepard Act at the federal level also did not provide protection for the transgendered individual if they were to be attacked.  Miss Green needlessly lost her life for the reason that someone hated her because of who he thought she was.  Thanks to the expansion of the Matthew Shepard Act in April of 2009, when Dwight DeLee, Lateisha’s murderer, went to trial on July 13, 2009, he was found guilty and convicted of first degree manslaughter as a hate crime just four days after the trial had begun (Human Rights Campaign, 2009; The Lateisha Green, 2009).

Standards of Care and DSM Criteria

The transgender individual faces a list of various steps to complete their transition from the gender they are born with to the gender they feel they were supposed to be.  In order to achieve their desired results, the Harry Benjamin International Gender Dysphoria Association (HBIGDA) introduced the Standards of Care (SOC) for Gender Identity Disorders in 1979.  They have been revised five times to meet today’s standards, with the latest edition having been revised in 2001 (Meyer III, M.D. Et Al, 2001).   In the SOC, the World Professional Association for Transgender Health, Inc. (WPATH) explains the areas of focus on gender identity disorders, which include Epidemiological Considerations, Assessment and Treatment, Psychotherapy, Requirements for Hormone Therapy for Adults, the Real-life Experience, Surgery, and Post-Transition Follow-up.  They state that the universal objective of psychotherapeutic, endocrine, or surgical treatment designed for individuals with gender identity disorders is a lifelong individual reassurance with the gendered self in order to get the most out of their overall psychological welfare and self-fulfillment (2001). The HBIGDA SOC is included in Appendix A.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) did not have a diagnosis for transgenderism or transsexuality prior to their release of their DSM-III.  It was only in this third edition that the American Psychiatric Association used the term transsexualism for the first time, making it a mental disorder in the mental health and medical field (1980).  This terminology again was changed in the DSM-IV (1994) to GID, or gender identity disorder, in which there were three classifications, Gender Identity Disorder in Children or Gender Identity Disorder Not Otherwise Specified (NOS), 302.6 and Gender Identity Disorder in Adolescents or Adults, 302.85.    Because of this definition, many people believe that transgender people are mentally ill, however some authors believe that having a transgender identity is not in and of itself being “mentally disordered” (Israel & Tarver, 1996; Melby, 2009).  “Regardless of the stage of life in which individuals with gender identity disorder find themselves, the key root of their cross-identification behavior is the conflict over their biological sex role and their perceived sexual identity” (Kirk & Belovics, 2008).  Various people consider that gender identity, or the individual ideas of being a man, woman, both, or neither, is fixed in biology, although what the genetic “cause” of gender identity may be, has by no means been established (Stryker, 2008).  The DSM criterion for gender identity disorder is discussed in the HBIGDA as part of the understanding of transsexualism as well as being included in Appendix B.

With a new interest in treating the transgender individual through therapy and medicine, as well as the advancements that have been made over the last thirty years, ideas on how to treat transgender individuals are expanding every year.  In 2004, Aaron Devor, a professor of sociology at the University of Victoria, proposed a fourteen stage model of transsexual identity formation built upon Cass’ model of homosexual identity formation (cited in Devor, 2004).  This model is included in Appendix C and is a profound source to assist the Gender Specialist in counseling the transgender client.

Many people believe that removing the diagnosis of GID from the DSM in the fifth edition, scheduled for release in 2012, and would be a move compared to the likes of the removal of homosexuality from the DSM-III (1980).  Although this would be more acceptable among the transgender population, the problem with doing so would ultimately be grounds for insurance companies to deny any kind of assistance in the mental health of the transgender client or any physical treatment for their transition.  Without any assistance from ones insurance provider, many transgender individuals would not be able to get the help that they need in order to become who they truly are due to the high costs of hormone therapy and surgeries.

 

Assessment Process

With the Harry Benjamin SOC, we see that the requirement for both hormone therapy and gender reassignment surgery for the transgender client is to undergo psychotherapy for a minimum of three months before undergoing hormone treatment and a minimum of two years for the gender reassignment surgery.  When the transgender client first begins the process of searching to establish their gender reassignment, it is with the SOC that engaged mental health professionals need to assist them the most. 

Through their initial visits the therapist needs to complete the traditional assessment process as they would with any other client.  This may seem simple enough, but there are more areas of interest that the therapist may want to look at.  It is important that the therapist build a therapeutic rapport with the client, discuss the clients’ needs, goals and expectations, and evaluate the client’s history, objectives, and their psychological concerns along with their consent to care (Bockting, W.O, Knudson, G., & Goldberg, 2007; Hansen, Rossberg, & Cramer, 1972/1994; Israel & Tarver, 1996).  It is in this relationship that the therapist’s perception and understanding of the client’s behaviors are not only realistic but that their feelings are genuine and their behaviors congruent (1972/1994).  It is also vital that the therapist take a culturally sensitive approach to working with the transgender client (Gainor, 2000). 

Like any other field of study, transgender counseling can be more beneficial when done with a Gender Specialist or Senior Gender Specialist.  In their book Transgender Care, Gianna E. Israel and Donald E. Tarver II, M.D. (1997) explain the work of both of these specialized fields.

“The Gender Specialist may be a professional, paraprofessional, or peer-support care provider.  The Gender Specialist is an active practitioner in psychotherapy counseling, or education directly oriented toward gender-identity issues.  It is recommended that care providers interested in establishing themselves as Gender Specialists undergo a minimum of two years of direct supervision or consultation with a practicing Senior Gender Specialist who is recognized as having advanced experience in providing consultation to peer practitioners.

The Senior Gender Specialist is a care provider who has actively practiced as a Gender Specialist for five years.  Senior Gender Specialists are deemed appropriate to provide assessment and evaluation letters, as recommended for Genital Reassignment Surgery.  At their discretion, Senior Gender Specialists may also provide training, supervision, or consultation to Gender Specialists.

Care providers who hold advanced degrees in psychology, medicine, sexology, clinical social work, or other medical or mental health fields may become Senior Gender Specialists following two years of active practice while receiving consultation in a role as a Gender Specialist.”

In order to start the therapy needed for Gender (or Genital) Reassignment Surgery, the assessment needs to cover not only the basic information of individual and family mental health history, but also their some childhood history, physical health history, sexual/ marital history, and their transgender identification and the history involved with such.  A sample assessment or Gender Identity profile is included in Appendix D.

The assessment should be done in the early stages of counseling, no later than the fourth or fifth session, in order to determine any issues that will need to be addressed in treatment.  It is this assessment of gender concerns that involves a detailed history of transgender identity development and gender expression (Bockting, W.O, Knudson, G., & Goldberg, 2007).  This assists the client in developing trust and rapport with the psychotherapist.  It is through this assessment that the therapist finds if there are any key mental health issues at hand, such as schizophrenia, depression, anxiety disorders, adjustment disorders, addiction, or post-traumatic stress disorder, to name a few (Israel & Tarver, 1996).  Devor (2004) explains that each of us has a deep need to be witnessed by others for who we are and that we all desire to see ourselves mirrored in other peoples eyes as we see ourselves.  When these messages received in return from others are not equivalent of how one feels within, an assortment of psychological distress and maladaptive behaviors can result.

Through the assessment, the therapist can find the issues most important to the individual in order to treat the client in the proper fashion and not just address surface issues.  With gender identity being the more common reason that a transgender client sees a therapist, it is common that other issues are of more concern and need to be acknowledged appropriately in order to allow further gender identity treatments to take place.

 

Pre-Operative Psychotherapy

After the assessment has been completed, which should be within the first three to five visits, the therapist discusses the treatment plan with the client and makes a plan to address by agreement the more prominent issues at hand.  The issues that should be covered in sessions should be discussed with and approved by the client to ensure a direction and purpose for the sessions. It is in this stage of treatment that the client understands the issues with which the therapist is working to help.  Through treatment, the therapist promotes the clients understanding of both the risk factors, such as a higher risk of cancer or cardiovascular disease, and the consequences, such as the loss of relationships, entailed in the process.

In the course of the psychotherapy, the therapist is able to identify how early in life the client realized a difference in their gender identity and the factors that may have created this realization.  Usually one’s ideas as male or female are established early in life (as cited in Parlee, 1998; Harré, 1991).  This is found to occur during Erik Erikson’s initiative versus guilt stage of development (Berger, 1980/2006) and Jean Piaget’s preoperational stage (1980/2006).  It is during this age frame of three to seven years of age, in which individuals dealing with gender identity typically come to the realization that they were born in the wrong body.  The criteria listed for GID are descriptive of various individuals who experience conflict between their gender as assigned at birth and their gender identity, which is typically developed in early childhood and comprehended to be decisively established by age four, which agrees with both Piaget’s  and Erikson’s stages as mentioned above.  Nevertheless for some transgender individual, gender identity may remain rather fluid for many years (WPATH Board of Directors, 2008).   

During the therapeutic process, it is important that the client-therapist relationship work on many factors that may be connected to the feelings of gender identity, and that each one should be addressed at the appropriate times.  Some of these possible issues are substance abuse, black-market hormones, rejection, suicidality, depression, gender-based discrimination, loss of friends and family, and disclosure, which requires forethought and communication skills (Israel & Tarver, 1996; Top 10 Things, Unknown/2009), as well as medical, emotional, family support and employment risks.  On the other hand, the benefits that result from the transition are peace of mind to the client, the ability to complete the individual’s change of identity, including physical, social, mental, emotional, and the governmental identification changes to match the individual’s new identity, and the final gender reassignment transition (Yvette, personal communication, September 9, 2009).

Israel and Tarver said that “although we discourage the diagnosis of gender identity disorder as it is defined by the DSM-IV, we agree with the DSM-IV listing of the mental and biological issues that should not be confused with the evaluation of gender-identity concerns” (1996).  It is because of these many concerns that HBIGDA has required that any individual seeking gender reassignment surgery needs to seek a mental health professional for a minimum period of two years before their gender reassignment surgery and a minimum of three months before commencement of hormone treatment (Meyer III M.D., W., Bockting Ph.D., W. O., Cohen-Kettenis Ph.D., P., Coleman Ph.D., E., DiCeglie M.D., D., Devor Ph.D., H., et al., 2001).

During the mental health treatment process, there are many possibilities for helping the client in their mental health needs, including, but not limited to: individual counseling, self-help and social support groups, and group psychotherapy.  Also it is important to help the client’s immediate family members and spouse individually, or conjointly if they so desire, in order for them to be able to understand the gender reassignment process and so that they can discuss any issues that they may have about their loved one as well.  Besides family therapy, it may also be important to the spouse/ partner to be involved in relationship therapy along side the transgender client, in order for them to be able to focus their effort on issues in their relationship regarding the transition process.

 Because of the limited amount of time that the therapist has with the client, it does not allow them to be there for the client through all facets of the gender reassignment, but it is imperative that they become acquainted with each of the physicians involved in the client’s physical health care.  Through the psychotherapeutic process, the therapist helps the client going through the gender reassignment treatment to remain mentally well.  There are many guidelines recommended concerning mental health treatment are have been included in Appendix E. 

 

 

Hormonal Therapy

With hormone treatment being the first step that is taken after psychotherapy treatment has begun, the therapist not only needs to be involved in the client’s mental health, but should remain in contact with the physician in charge of the hormone therapy in order to assist in the monitoring of potential concerns with the clients mental and physical health.  This is extremely important as the client begins this part of the treatment as there are many new concerns that can come into play.  These can include, but are not limited to, cancer, including breast cancer (MTF), higher lipid levels, mood changes, heart disease, acne, and male-pattern baldness (FTM) (Israel & Tarver, 1996).  For the treatment of hormone therapy, it is important to understand the many difficulties that the client may face through this stage of the process, as these may be indicators to future concerns. 

For many transgender individuals, the hormone therapy is sometimes the only treatment that they will receive; therefore it is vitally important to closely monitor their mental health.  With the increase of estrogen in MTFs and testosterone in FTMs, many side effects can come along with these hormonal differences.  Transgender hormone administration may play a causal role in depression and therefore should be monitored closely by both the prescribing physician and the therapist.  Other concerns with hormone therapy are cardiovascular health, cancer, risks involved with smoking after hormone treatment has begun, as well as the client’s diet.

One of the key factors during all stages of the gender reassignment process is finances.  This becomes an important issue in hormone therapy as most insurance companies will not cover hormone therapy for gender reassignment issues.  Since this becomes a major concern, the probability of the transgender client obtaining black-market hormones is not uncommon.  Sadly the problematic issue with black-market hormones is that if the client is having an adverse reaction to the medications or their dosage needs to be re-regulated by their physician, it goes unnoticed thus becoming a major health matter.  In the end, black-market drugs can ultimately develop into higher costs for the client due to additional costs associated with additional physical and mental health issues.  It is advised that the therapist help keep a close eye on the client’s hormone use and advise them to keep their regularly scheduled appointments with their physician in order to maintain appropriate dosages and hormones for their treatment.  The hormones and their individual dosages are listed in Appendix F.

From Fantasy to Reality: the Real-Life Test

After the transgender client has been in psychotherapy treatment for approximately one year, and after they have begun hormone treatment, the next process is moving from the temporary lifestyle of cross dressing to the permanent lifestyle changes and commitment to the new gender.  This process, although not necessary in all transgender treatments, is a vital step for the transsexual in order for them to realize their new individuality and transition from a temporary state of self to a permanent state of altered gender identity.

When the client has been cross dressing in the past, this has been a temporary identity change or acting out.  At some point the client needs to realize and act in a permanent fashion as a transsexual.  Many of the areas here consist of experimenting with their looks, a new self expression and an exploration of who they desire to be after their transition is complete.  It is important that the client realize the importance of this change and make a complete commitment to their new identity.

According to Israel and Tarver (1997) and HBIGDA (2001), this process is known as the real-life test.  It is a term used to illustrate the phase from beginning to live in role, to the time when he or she has been doing so long enough to be considered a suitable candidate for aesthetic or Gender Reassignment Surgery (1997).  Apart from the SOC  by which a real-life test protocol is defined, few specialists believe that care providers and transgender individuals place too much importance on the quantity of time one must expend living “in role” preceding the  recommendations for surgery.  The real-life test however is essentially designed to care for and reduce the risk of non-transsexual and unprepared individuals from undergoing surgical procedures and incurring physical, psychological, and/or social injury.

There are other changes that occur through the process that can change the transgender individual’s lifestyle choices, their relationships, sexual partners, and even their sexual identities.  For example, family relationships are challenged by many transgender clients’ families because of fear or the lack of understanding.  This is important for the client to help their family seek therapy as well in order to keep the lines of communication open during transition process.  Although this is usually considered a part of the pre-operative psychotherapy, many transgender clients choose to wait until they have begun hormone treatment or the real-life test to inform those that are closest to them.

Another possible change is that of sexual identity.  Sex is not who one is as an individual, it is a part of one’s identity in relationship to others, for this reason, many therapists have confused sex and gender for many years and this should be corrected in the fields of psychology, sociology, and medicine. Generally people experience sexual orientation and gender identity as two separate things (APA, 2008). Sexual orientation refers to one’s sexual attraction, while gender identity refers to one’s sense of oneself as male, female, or transgender (2008).  The transgender client can have any number of the various sexual identities, including homosexual, heterosexual, lesbian, bisexual, nonsexual, or asexual.  There is no rhyme or reason as to what causes ones sexual identity to change in some transgender clients, but many transgender’s have had a sexual identity of heterosexual prior to their transition and after their transition have become homosexual or lesbian, bisexual, nonsexual, asexual or remained heterosexual. 

Life Skills Training

Life skills’ training is a process of the transition that is not distinctly discussed in the literature, although it is mentioned in the transgender community.  This process consists of learning new skills that identify the transgender individual in their new gender expression.

For MTF clients, there are basic skills that one needs to learn in order to pass as a female.  Some of these include, learning how to shop for women’s clothing with help from a style counselor, which includes how to properly know ones own bra size, what colors and styles of clothes to wear and how and where to shop responsibly, how to apply makeup properly, learning how to walk as a woman, and voice coaching.  Although these seem like miniscule skills that one needs to learn, to the transgender MTF they are very important.  If one is unable to pass as female, there is the fear of being fired from one’s job, being discriminated against in public situations, or being beaten, tortured, or even killed.

For the FTM transgender, some of these basic skills include, voice coaching, dressing in more masculine clothing, and learning to walk in a more masculine way.  The voice coaching for FTM is not as big of a need as it is for MTF as the testosterone will start to thicken the vocal chords causing the client to begin speaking in a lower register.

Gender Reassignment Surgery

For the transsexual individual gender reassignment surgery, for at least part of this population, is the final step to the completed transition process to the client’s new identity.  This process involves a multitude of various surgeries for the male to female transition compared to the female to male transition.  To understand this population better, we need to know that not all transgender clients undergo surgery.  The estimated numbers, although these numbers are most likely lower than actual transsexuals, total  approximately 10,000 to 12,000 MTF transsexuals and 5,000 FTM transsexuals (Ulm, 2009) and approximately 400,000 transgender individuals in America (Kennedy, 2008).  Comprehending these numbers on a more understandable scale, Ulm and others say that male bodied people who become women are approximately one in 11,900, while female bodied people who become men are roughly one in 30,000 people (Currah, Juang, & Minter, 2006; Rohde, 2009; Transgender, 2009; Ulm, 2009), although these numbers are continuously changing as more and more transgender individuals are coming “out of the closet” about their transgender identity.  With these figures, it is estimated that in a city of approximately 125,000 people, there would be roughly 11 MTF transsexuals and 4 FTM transsexuals. 

There are two different types of surgeries available for both FTMs and MTFs, aesthetic surgery and the genital reassignment surgery.  According to Israel and Tarver (1997), it is virtually impossible to fulfill the real-life test, which was discussed earlier in this paper, and be fully functioning in the capacity of a new gender identity without some prior surgical intervention.

For the MTF clients, there is the option for breast augmentation surgery.  While interviewing Amanda in her personal communication (September 12, 2009), she said that she chose breast augmentation for two reasons; the first was to remain off the hormones in order to continue to have sexual intercourse using her male anatomy, and two because of the possible side effects of hormones.  The second option for breast enhancement without hormone treatment is silicone injections.  This has become one of the most unethical procedures towards MTF transsexuals, as it has been declared illegal by the United States and in most countries with similar food and drug precautions due to its (silicone) ability to migrate through the body causing dangerous side effects to major organs. Unfortunately, unscrupulous and deceitful doctors and other practitioners preying on the transgendered community have been found to continue to offer this form of treatment (1997).  There are several other aesthetic surgeries for MTFs, including tracheal shave, voice augmentation, false rib removal, rhinoplasty, face lifts, acid peels, chin reductions, forehead lifts, brow shaves, electrolysis (hair removal), cranial reconstruction surgery, and hair transplants.

For FTMs, the earliest possible and most common surgery is a bilateral mastectomy or chest reconstruction, which can be completed after a minimum of three months of psychotherapy treatments.  Part of the reason for such an early timeframe for this surgery is due to the higher risk of breast cancer when testosterone treatment has begun.  Dermatological treatments have become common as well in the FTM population due to severity of acne scarring from the hormone treatments.  Although there are many other types of aesthetic surgeries available, these have been seen as the most common procedures being performed in the early stages of the transgendered client’s transition.  Douglas Ousterhout (cited in Israel & Tarver, 1997) says that “the procedures being completed need to be chosen on an individual basis.”

Genital reassignment surgery itself is the most prominent procedure the transgender client is concerned with during the transition process.  It is important that the client complete a minimum of two years of therapy with a psychologist or psychiatrist (or in some cases it is recommended from both) before undergoing this major step in the process.  The two main reasons for this are, 1) to not rush into making a decision that they are unable to reverse after it has been completed, and 2) to protect the physician from a malpractice suit by performing a surgery that the client was not prepared for.

The genital reassignment procedures include the removal of the gonads and genital removal as well as reconstructive procedures such as hysterectomy, oopherectomy, salpingectomy, vaginectomy, genitor-phalloplasty, and metoidioplasty for the FTM individual; or orchidectomy, penectomy, genitor-vaginoplasty, or labioplasty, which is completed no sooner than three months after genital reassignment surgery for patients who desire it (Schrang, 1997) for the MTF individual.  There are two options for surgery when considering the genitals which include the complete genital reassignment surgery or a gonad-removal surgery in which only the reproductive glands are removed.  Both HBIGDA (2001) and Israel & Tarver (1997) have given the SOC and recommended guidelines stating that either of these types of surgery requires a minimum of two years before either surgery can be completed.  These procedures and their definitions can be found in Appendix G.

There are several concerns after surgery with health related complications beyond the traditional surgical procedure.  After the GRS, FTMs have a greater risk than MTFs with health related concerns.  This is usually in part to the fact many FTMs do not complete their transition and maintain their female reproductive organs.  This main risk is not only in part to common causes of cancer or other health issues, but the increase in testosterone can raise the chance of cancer related health problems in the ovaries and cervix.  This was the case for Robert, a FTM transsexual who did not have his ovaries removed and eventually passed away from cancer because doctors were afraid to treat him until it was too late (Cola, 1999).  His documentary was released two years after his passing to tell his story (Davis, K., 2001).

Post-Operative Therapy, Termination in Counseling and a Continuing Process

Although post-operative counseling, like the life skills training, is not clearly defined in the majority of the literature, it is strongly recommended that the transitioned transgender client complete their therapy after their transition.  Many issues that may have been resolved in pre-operative counseling may or may not show up again and new issues at hand may need to be addressed.

Israel and Tarver (1997) suggest that the responsibility of the Gender Specialist does not finish with pre-surgical therapy, evaluation, or providing a letter of recommendation.  A competent Gender Specialist will recognize the need to present post-surgical follow-up and its necessity for the client.  Through the post-operative mental health check-in, the Gender Specialist provides an opportunity for the individual to talk about his or her recent experience, and can recommend additional resources and options for the client, should difficulties arise in the future.  This is best to be completed within the first month after their GRS and this one session is provided by some Gender Specialists, not all, as a courtesy session which creates the additional incentive for post-operative client to seek support with any difficulties that they be having as a result of surgery.

It is at this time that the therapist will determine if other factors, such as post-traumatic stress, loss of family or extended-family support, housing, or employment, complications with identity related documents and governmental issues with documentation, depression, adjustment, or anxiety, or any number of these may present for further therapy (Carlson, 1996/2002; Israel & Tarver, 1997).  It is during this time that the client can receive any additional counseling that may be needed.  At this time the therapist can also help the client and work with other organizations that may be beneficial in these areas as well.

Should no other concerns arise after the GRS, the therapist can help the client move on through the termination of therapy in agreement with the client.  This termination is not only dependant on the counselor, but also on the client as they see their ability to move forward without the need for therapy.  This is not dependant on only one or the other, but on both the client and the therapist and should be agreed on as to a timely manner to terminate the counseling process (Hansen, Rossberg, & Cramer, 1994).  The termination process is one that can be complex because of feelings of ambivalence about it.  The client equally wishes to be liberated from the counseling process and is sometimes apprehensive about parting the process as well (1994).  It is because of this that the counselor emphasizes the fact of ending the counseling process carefully and not just abruptly as to not further impede any unresolved issues. 

In their book, Counseling: Theory and Process, the authors discuss the termination stage of counseling as  having three primary functions as presented by Ward (cited in Hansen, Rossberg, & Cramer, 1994).  These three functions consist of: 1) evaluate the client’s readiness to finish the counseling process and merge their learning, 2) resolve any outstanding emotional issues and bring the relationship involving the client and counselor to a close, and 3) to make best use of the client’s transfer of learning and enhance his or her self-reliance and confidence in the capacity to retain the transformation.

In the termination process, it is important to inform the client that this does not mean that they can never be seen by the counselor again.  Albeit, this may be the end of this portion of counseling, the therapist should inform the client that their office is always open for them to come back to at any time to work through any issues that they may need to address in the future.  Just because the client-therapist relationship has come to a close at this time of their transition, it does not mean that they are not allowed to consult the therapist in the future for any circumstances that may arise in their lives.  If the client feels that the counselor would be better suited to help them with a situation they are unable to face alone, they should feel welcome to visit the therapist at a later time.

Ethics

            Once again, there was no real definitive literature on the topic of ethics; however, due to the nature of the subject, it is good to be reminded of some of the ethical principles for therapists.  A few new principles can be added to the therapists ideals from various research and literature for future use as well.  With very little being discussed in relation to ethics in the literature, there are some rules of thumb not only for the counselor but for the client as well when it comes to ethics.

“There are merchants and care providers who prey on transgender individuals who are closeted or unaware that other resources exist.  The unscrupulous (counselors and physicians) take advantage of a transgender person’s sense of desperation,” (Israel & Tarver, 1997).  In the interviews completed at the end of filming the movie “Transamerica,” Felicity Huffman believes that “it is not a transgender issue,” in regards to the film, “it is a human issue” (Tucker, 2005).  Just because the transgender individual is seeking the assistance of a therapist for their mental health, as well as trying to find authenticity through GRS, this does not mean that they are individuals that are worth trying to deceive every dime out of them because of who they are, or for who they desire to be.

Care providers encountering transgender issues, not only for the first time, are advised to keep in mind that it is the provider’s liability to pursue the ethical and professional guiding principles customary for their area of expertise, and to guarantee that the transgender client is taken care of with the same dignity, respect, and quality of care unmitigated to others, regardless of how atypical an individual’s requests and thoughts may seem (Israel & Tarver, 1997).  “Awareness of the ethics codes is crucial to competence in the area of ethics, but the formal standards are not a substitute for an active, deliberative, and creative approach to fulfilling our ethical responsibilities” (Ethics Codes &, 2009).  With this in mind, psychologists and psychiatrists should adhere to either the American Psychological Associations “Ethical Principles of Psychologists and Code of Conduct” (2002) or to the American Psychiatric Association’s “The Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry” (2009).  A copy of the American Psychological Associations Ethics Principles is listed in Appendix H. 

Conclusion

Transgenderism is not always a painless path to follow (Hotchkiss, 1995), and transgender individuals, as well as their loved ones have often been an underserved community that are in need of empathic, comprehensive, and clinically competent care providers who are not there to judge or try to mislead them in any direction.  With the knowledge that has been presented in this paper and through the research undertaken, any motivated mental health care professional or counselor will be able to come to the same knowledge and level of empathy and compassion that is needed to counsel these clients.  The knowledge that has been obtained in this research, although extensive in some areas and minimal in others, would be an excellent source for the person seeking to become a Gender Specialist.   As a result of this research, appropriate terminology is now properly understood and unacceptable terminology was corrected and should be explained to individuals interested in becoming a Gender Specialist as well as the transgender client, their loved ones, and throughout the educational system.

The entire transition process, when looked at prior to the research, can seem not only daunting, but also seems very complex.  After reading about the process and studying the fields of psychology or psychiatry, one should be able to assist a transgender individual throughout their transition with a positive outcome.  This will also help the therapist to challenge their own stigmas and be able to confront their own feelings and fears.  To say there is no challenge in this field would be a lie, as no therapist has all of the answers.  The challenge in this area of study is that it is still new in the field of mental health that many more issues need to be explored and understood in order to resolve the possible psychological consequences for the transgender client.

Many patients need to take time due to the cost of the entire process, which can run into hundreds of thousands of dollars in some cases.  Likewise it is also important that the therapist does not try to extend the psychotherapy sessions longer than needed. With economic restraints taking their toll on many transgender clients, the therapist needs to be more empathic and understanding when it comes to recommended time lines that they may give to the client.  With a typical time frame of two and one half years from the beginning of the counseling process to the completion of post-operative psychotherapy, it is also important not to set specific time frames and to allow for other issues that may need to be addressed prior to any further treatments. 

Finally, it is imperative to understand that post-operative counseling is just as important as pre-operative counseling.  With almost no literature on post-operative counseling, it is important that further studies are necessary to understand this part of the transition process.  With the various areas of study within the topic of transgender transitioning, it is highly recommended that further research be completed for the Gender Specialist and for transgender clients and their families.

References have been removed as well as the appendices having been removed as well due to length of information. In all there were a total of  53 references for this research.

Gender Identity Disorder Diagnosis and the Diagnostic Statistics Manual, Fourth Edition, Text Revision Sunday, Aug 29 2010 

Abstract

Appreciating and counseling the patient with Gender Identity Disorder is not always an easy task.  Each counselor must comprehend the in depth ideas to these individuals who need assistance with their mental health needs and their individual diagnostic needs.  Considering the etiologies, the differential diagnoses, and the treatment strategies available not only to the client but for the therapist as well to help the client in their needs is an understanding that every therapist should learn and know.

Introduction

With the emergence of numerous psychological concerns in therapy over the years, one may suggest that counseling the transgender individual, or a client diagnosed with Gender Identity Disorder, is even more of a challenge than perhaps any other concern in this field of study.  In order to understand the transgender person and their mental health requests, the therapist should not only concern themselves with the various matters that could arise in the counseling sessions, but they should conduct an in-depth assessment of who the transgendered individual is as a human being and what other possible concerns they might have relating to their identity.  

With the evolution of medical science, it is no wonder that the field of psychology is seeing a rise of individuals needing the assistance of professionals in determining if complete gender reassignment surgery is appropriate for them or if a less radical procedure (e.g. only hormone treatment, psychotherapy treatment alone) would be in order if one is called for at all.

With the amount of time given to complete this undertaking, some therapists may perhaps find it complexing to recognize the nature of Gender Identity Disorder, or Transgenderism in main stream thought, in a short period of time.  With an assortment of issues that can present themselves throughout the path of an individual’s transition, the inexperienced therapist may find it easier to refer the client to a more qualified therapist in the field and then decide to gain the information needed in assisting such individuals. 

Gordon Allport once said that “the goal of psychology is to reduce discord among our philosophies of man and to establish a scale of probable truth” (1955), and in one of his previous texts he relayed that “general psychology…selects a single attribute or function that can be conveniently isolated for study” (Allport, 1937).  It is no surprise therefore, that there is a need to counsel each of these individuals with a more open mind, complete understanding, to beware of our biases, and to be cautious and  aware of our own manifesting countertransference issues that could surface for even the most culturally sensitive and experienced therapist.  It is because of the refinement of my personal biases, and the newly understood education that I have acquired from good friends who have been diagnosed with Gender Identity Disorder (GID) over the last two years, that I have had a better understanding of GID and have become an advocate on their behalf for the last 18 months with hopes to have it removed from the DSM-5.  It is because of these truly wonderful, remarkable, and brave individuals that GID was chosen to be written about in this research.

Hypotheses Regarding Etiology

            With as many as 3.04 million individuals in the United States living with GID, rather diagnosed or not, it appears that this area needs to be highly addressed in regards of diagnosing people without setting a stigma on them.  Unfortunately, because of our societal norms, a stigma has been set on any mental disorder that we diagnose a patient with, and in an area such as Tulare County, where as many as 4,200 people, again are or are not diagnosed with GID, stigmas need to be addressed in order for these individuals to receive treatment as to not harm themselves, such as in the instance of Martina, who earlier this year took her life in Visalia because of the lack of assistance she was unable to find.  And with suicide rates for individuals with GID being more than 50 per cent in some studies (University of New Hampshire, 2008), with these statistical numbers, it is a good thing to understand the etiology of GID in order to be able to treat it appropriately.

                        The Diagnostic and Statistical Manual of Mental Disorders did not have a diagnosis for transgenderism or transsexuality prior to their release of their DSM-III.  It was only in this third edition that the American Psychiatric Association used the term transsexualism for the first time, making it a mental disorder in the mental health and medical field (1980).  This terminology again was changed in the DSM-IV (1994) to GID, or gender identity disorder, in which there were three classifications, Gender Identity Disorder in Children or Gender Identity Disorder Not Otherwise Specified (NOS), 302.6 and Gender Identity Disorder in Adolescents or Adults, 302.85.    Because of this definition, many people believe that transgender people are mentally ill, however some authors believe that having a transgender identity is not in and of itself being “mentally disordered” (Israel & Tarver, 1996; Melby, 2009).  “Regardless of the stage of life in which individuals with gender identity disorder find themselves, the key root of their cross-identification behavior is the conflict over their biological sex role and their perceived sexual identity” (Kirk & Belovics, 2008). 

            In Pauly’s article “Terminology and Classification of Gender Identity Disorders,” the author states that clinicians have been describing patients with some form of gender discomfort for more than 150 years (1992).  Since 1830, German clinicians have written about gender dysphoria in various European literature.  Since 1980, the American Psychiatric Association (APA) has been explaining GID in one form or another in the DSM and since then, numerous individuals as well as many organizations have been pressuring to have the removal of GID from the DSM completely.

There are several current theories about the causes of GID and these appear to include chromosomal abnormality, hormonal imbalance, and impaired early parent-child bonding and child-rearing practices (Causes of Gender Identity Disorders, 2010), although none of these could actually be confirmed in literature. 

In “The Theory of Gender Identity Disorders”, Meyer reviewed existing hypotheses stating that there are three of them regarding “transsexualism” which is the previous term to Gender Identity Disorder in the DSM-III.  These three hypotheses include the biological/ imprint hypothesis, the nonconflictual hypothesis, and the conflict/defense hypothesis (1982).

In his first hypothesis, Meyer views the biological/ imprint hypothesis of transsexualism as the “unfolding of a predisposition or the manifestation of a biological vulnerability.”  He also states that Money and Gaskin believed that transsexualism to be a clinical syndrome, possibly triggered by “critical period affects.”  Both of these ideas would be supported by the thought that one’s ideas are established early in life as male and female (Parlee, 1998; Harré, 1991).  Various people consider that gender identity, or the individual ideas of being a man, woman, both, or neither, is fixed in biology, although what the genetic “cause” of gender identity may be, has by no means been established (Stryker, 2008). 

This is found to occur during Erik Erikson’s initiative versus guilt stage of development (Berger, 1980/2006) and Jean Piaget’s preoperational stage.  It is during this age frame of three to seven years of age, in which individuals dealing with gender identity typically come to the belief that they were born in the wrong body.  The criteria listed for GID are descriptive of various individuals who experience conflict between their gender as assigned at birth and their gender identity, which is typically developed in early childhood and comprehended to be decisively established by age four, which agrees with both Piaget’s  and Erikson’s stages as mentioned above.  Nevertheless for some transgender individual, gender identity may remain rather fluid for many years (WPATH Board of Directors, 2008).   

With the previous notion that there is a chromosomal abnormality, we now take a look at the biological etiology of GID.  Zhou, Hoffman, Gooren, and Swaab looked at the bed nucleus of the stria terminals (BSTc) to see if this area of the brain would possibly be due the reason for sex differences and its correlation on transsexuality (1997).  In their study, which was the first of its kind, the authors show a female brain structure in genetically male transsexuals which supports their hypothesis that gender identity develops as a result of an interaction between sex hormones and the developing brain.  In their main findings however, they found no relationship between the BSTc size and sexual orientation, yet they believe that this decrease is size of BSTc in male-to-female transsexuals is related to the gender identity alteration instead.  This research should be replicated again using pre-operative and post-operative, pre-hormonal therapy and post-hormonal therapy transsexuals as well as non-transsexual individuals to see if the findings agree.

Biologically, the transsexual debate continues on with such research as “The Heritability of Gender Identity Disorder in a child and Adolescent Twin Sample” (Coolidge, Thede and Young, 2002) and Blanchard and Bogaert’s “Homosexuality in Men and Number of Older Brothers”.  Many other thoughts have been explained on this hypothesis, yet at this time none of them were able to be located for this research.

Although the second hypothesis by Meyer, nonconflictual identity, did not seem to hold up any relativity in this research, the third hypothesis of conflict/ defense appeared to have validity.  This hypothesis which has been supported by numerous other authors, has a probability that transsexualism is the result of an unconscious conflict from the earliest years of life (1982).  Socarides (1969) regarded transsexuality as an attempt to ward off paranoid psychosis that might develop if one engaged in homosexuality. (This is why as therapists, we need to look at the differential diagnoses to make sure that we are not misdiagnosing a patient.)  Many others as well agreed that transsexuals choose their identity as to avoid another possible issue that may actually be a concern at hand.  Some of these concerns will be further addressed under the differential diagnoses in the next section.  It is for this reason that the Harry Benjamin International Gender Dysphoria Association (HBIGDA) introduced the Standards of Care (SOC), which has been revised numerous times in order to meet today’s standards for Gender Identity Disorders.  It is in the SOC that the World Professional Association for Transgender Health, Inc. (WPATH) explains the areas of focus on GID’s and states that the universal objective of psychotherapeutic, endocrine, or surgical treatments are designed for individuals with GID to receive a lifelong reassurance with their gendered self in order to get the most out of their overall psychological welfare and self-fulfillment (2001).  In addition to these etiologies, other possible causes of GID are constantly being researched in this in depth field of study.

Differential Diagnosis

            In understanding these differential diagnoses, one needs to be aware of the current criteria of the DSM-IV-TR’s GID diagnosis.  This includes:

  • A. A strong persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex). In children, the disturbance is manifested by four (or more) of the following:
  1. Repeatedly stated desire to be, or insistence that he or she is, the other sex.
  2. In boys, preference for cross-dressing or simulating female attire; In girls, insistence on wearing only stereotypical masculine clothing.
  3. Strong and persistent preferences for cross-sex roles in make believe play or persistent fantasies of being the other sex.
  4. Intense desire to participate in the stereotypical games and pastimes of the other sex.
  5. Strong preference for playmates of the other sex.

In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex.

  • B. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex.

In children, the disturbance is manifested by any of the following:
In boys, assertion that his penis or testes are disgusting or will disappear or assertion that it would be better not to have a penis, or aversion toward rough-and-tumble play and rejection of male stereotypical toys, games, and activities.
In girls, rejection of urinating in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate, or marked aversion toward normative feminine clothing.

In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex.

  • C. The disturbance is not concurrent with physical intersex condition.
  • D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Code based on current age:

  • 302.6 Gender Identity Disorder in Children
  • 302.85 Gender Identity Disorder in Adolescents or Adults

Since its inception in 1952, the DSM has had a number of revisions with various disorders removed as well as added to the plethora of disorders throughout the years.  With the introduction of transsexualism in the DSM-III in 1980, a new idea and criteria was born to diagnose an individual based on characteristics inherent to the opposite gender.  With criteria under the GID in the DSM-IV-TR including a repeatedly stated desire to be the opposite sex and discomfort of one’s own sex, it is not surprising why as professionals we need to be aware of these differentials.

The first differential is the simple nonconformity to stereotypical sex-role behaviors.  With more parents allowing their children to express themselves more openly, and more adolescents and adults finding themselves more open minded in regards to stereotyping, it is no surprise that this was the first differential listed.  Just because a boy plays with a doll or a girl gets dirty does not mean that these children need to be diagnosed with GID.

Another differential is the possible confusion between GID and transsexual fetishism.  Typically when a heterosexual or bisexual man dresses the part of a woman, this part is for sexual excitement.  Typically these individuals have no previous childhood cross-gender behaviors that would indicate the need to diagnose them with GID.  However, if gender dysphoria is present as explained in the DSM, with a lack of the full GID criteria, the specifier With Gender Dysphoria can be included.

Another Careful consideration when diagnosing would to be careful not to confuse GID with GID NOS (Not Otherwise Specified).  GID NOS is usually given in situations where the individual is showing signs of intersex conditions along with gender dysphoria.  There are also transient, stressor related cross-dressing behavior, such as males performing as females for entertainment such as drag queens, or a persistent preoccupation with castration (with the removal of the testicles) (also known as orchidectomy) or penectomy (the surgical removal of the penis) with no desire to acquire the sexual characteristics of the female.  This last definition, although does not define as such for the woman, (i.e. oopherectomy, the operation of removing one or both ovaries, or vaginectomy, the surgical removal of all or part of the vagina), it is the authors understanding that the terms defining GID NOS criterion number three are implied for females as well.

The final differential diagnosis is one of greater concern to watch for.  The DSM-IV-TR gives the following criteria for schizophrenia, in which one would need to carefully examine a possible GID patient against these criteria as well in order to rule out any possible erroneous diagnoses.  These criteria include, but are not limited to, delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms (i.e. flattened affect).  Should these specific symptoms appear, then a diagnosis of schizophrenia would be more apt than a GID diagnosis.  When comparing these two diagnoses criterion in the DSM, we are able to notice that there is a vast difference that needs to be identified with careful detail as to not misdiagnose the patient.

Treatment Strategies

            When considering treatment options for the GID patient, one must consider the many options and the length of time that some of the treatments take when working with a client.  Like any other field of study, transgender counseling may be more beneficial when done with a Gender Specialist or Senior Gender Specialist, however if the client is unable to find a specialist, it is best to work with a therapist that is willing to look out for their best interests.  To understand a gender specialist and senior gender specialist over a traditional psychotherapist, in their book Transgender Care, Gianna E. Israel and Donald E. Tarver II, M.D. (1997) explain the work of both of these specialized fields.

“The Gender Specialist may be a professional, paraprofessional, or peer-support care provider.  The Gender Specialist is an active practitioner in psychotherapy counseling, or education directly oriented toward gender-identity issues. 

“The Senior Gender Specialist is a care provider who has actively practiced as a Gender Specialist for five years.  Senior Gender Specialists are deemed appropriate to provide assessment and evaluation letters, as recommended for Genital Reassignment Surgery.”

During the mental health treatment process, there are many possibilities for helping the client in their mental health needs, including, but not limited to: individual counseling by counselors who have an adequate knowledge base for understanding transgender, transsexual and GID issues in counseling (Carroll and Gilroy, 2002; Carroll, Gilroy, and Ryan, 2002; Ellis and Erikson, 2002 Schaefer and Wheeler, 2004), self-help and social support groups, group psychotherapy, having a transgender friendly office and staff (Kirk and Belovics, 2008), properly assess and diagnose GID patients (Koetting, 2004), hormone treatment (Asscheman and Gooren, 1992; Cohen-Kettenis and Gooren, 1992), endocrinology, surgery, and psychiatry (Seil, 2004).  Also it is important to help the client’s immediate family members and spouse individually, or conjointly if they so desire, in order for them to be able to understand the gender reassignment process and so that they can discuss any issues that they may have about their loved one as well.  Besides family therapy (Bockting, Knudson, and Goldberg, 2006), it may also be important to the spouse/ partner to be involved in relationship therapy along side the transgender client, in order for them to be able to focus their effort on issues in their relationship regarding the transition process.  Additionally, Devor’s Fourteen Stage Model of Transsexual Identity Formation could help likewise in treating individuals with GID and may assist them in their transition of their identity (2004).

Conclusion

Transgenderism is not always a painless path to follow (Hotchkiss, 1995), and transgender individuals, as well as their loved ones have often been an underserved community that are in need of empathic, comprehensive, and clinically competent care providers who are not there to judge or try to mislead them in any direction.  With the knowledge that has been presented in this paper and through the research undertaken, any motivated mental health care professional or counselor will be able to come to the same knowledge and level of empathy and compassion that is needed to counsel these clients.  With a typical time frame of two and one half years from the beginning of the counseling process to the completion of post-operative psychotherapy, it is also important not to set specific time frames and to allow for other issues that may need to be addressed prior to any further treatments.  It is also imperative to understand that post-operative counseling is just as important as pre-operative counseling.  With little to no literature found on post-operative counseling, it is important that further studies be undertaken to understand this part of the transition process. 

References have been removed for safety of keeping my paper as mine and to minimize plagarism.

What Does Love and Work Mean to People? Sunday, Aug 29 2010 

Discussion

 

When discussing the topics of love and work with individuals, for many people it is a night and day discussion. Some people feel that love is something good in their lives and that work is something bad in their lives.  Dr. Sigmund Freud said that “love and work…work and love, that is all there is” (Sigmund Freud Quotes, 2010), at another point he stated that “Love and work are the cornerstones of our humanness.”  With these two thoughts we could actually expand on Freud’s ideas of love and work and go even a few steps farther.  He also has been known to have stated that “If you can’t do it, give up,” “One is very crazy when in love,” “Whoever loves becomes humble. Those who love, so to speak, pawned a part of their narcissism,” and “The goal towards which the pleasure principle impels us – of becoming happy – is not attainable: yet we may not – nay, cannot – give up the efforts to come nearer to realization of it by some means or another.”  With these additional thoughts in mind, it appears that Dr. Freud believed on top of this that there was no way to be truly happy in this life.

After interviewing Mrs. Riddle on love and work, it appears that everyone’s ideas, (including my own personal ideas and beliefs), in regards to love and work are different, but not far off from Dr. Freud’s.  Because love is such a focus in our culture, I chose to ask three of my questions in regards to love and the remaining two in regards to work.  The following is a partial transcript of the interview that took place with Mrs. Riddle on February 18th and March 1st.

  1. 1.       Can you define what love means and elaborate on your answer?

Love is undefineable and unexplainable. There are many ways to love. You love your children in one way, your spouse in another way, your parents in a different way, your friends a totally different way; you don’t love all of them the same way.  Love is painful.  For example, when my oldest son came out to me that he was gay; I thought my world had ended.  His father and I did not raise him that way and we could not believe that our son had turned out gay. Love can be beneficial and the lack of love can destroy a person’s soul.  A person who has no love in their lives is a person who does not know how to give love.  For example, there was this old lady that we lived next door to when we lived in Reedley in 1976. This lady had no idea what the meaning of love was because every time she would see my oldest son, who was only three years old at the time, she would call him a “God-damned little brat.”  How could have this lady known what love is when all she knew how to do was be a cold hearted person to a little child?

  1. 2.       How much of your life evolves around love? Please explain how you have come to this conclusion.

We are born into love.  From the day we are born, we know one thing that is true, and that is love.  I first knew love from my family, my parents and my siblings.  When I met my husband, I knew a new kind of love.  Then I had two children, both boys and I found that there is another kind of love.  So from the moment we come into this world we know what love is and it is all around us.

In my life I have had two major relationships; the first was a boyfriend I had for less than a year. His name was Benny and that relationship did not last because I was not going to have a man tell me how to live my life and he told me to shut one time, and that was one too many times, so I never spoke to him again.

The second relationship was with my husband of 40 years.  Although there have been ups and downs, times where I have wanted to divorce him and leave him for his stupidity.  The main things that have brought this on are bills/money, his parents (the old In-Law scenario), and television.  However, I would have to say that our marriage has been a success overall.  I love him more and more each day and could not imagine my life without him.            

  1. 3.       Is love the most important quality of the human soul? Why or why not?

I believe that we cannot live without love. If we think about it, without love a person becomes susceptible to becoming a bitter unlovable individual who is incapable of showing love to anyone else.

After discussing with Mrs. Riddle her thoughts on love, she appears to have had a successful life with people who love her. Although she lost her grandfathers at the age of 16 and 19, her grandmother at the age of 16, her father at the age of 49, and her mother at the age of 61, she has found comfort in loving the rest of her family; four siblings, her husband, her two sons, and their life-partners.

With how she was describing love, it was the same concept as Harry Harlow’s experiment with the wire monkey and the soft monkey.  Although there was no love and affection, the monkey found the comfort in the softness of the soft monkey.

  1. 4.       How would you define work?

Mrs. Riddle defined work as something everyone has to do in order to truly live; “We have to work in order to eat and have a place to live.”

Although she was not able to work any kind of full-time position as an adult because of her health, she knows that if she would have had no other choice she would have sacrificed her health to make sure there was a roof over her children’s heads and food in their stomachs.

Through the years, Mrs. Riddle worked approximately two years in fast fast food services, a year cleaning the church her family attended in the eighties, two years of Avon sales, a year of Home & Garden Party sales, and has put in fifteen years of volunteer service for her churches she has attended and her local senior center.

  1. 5.       Is work a chore or is it a transfer of your energy in order to earn money?  What reasoning do you have for your answer?

Although work can be hard, anything in life can be worth working for and rewarding.  She believed that work should be something you enjoy not a chore that you hate.  Her idea of work is yes it can be a chore, some of the things we have to do at work are not things we want to do or things we may even enjoy, but it is also that transfer of your personal energy to receive that income. 

She also mentioned that if she would have had to do it all by herself, it would have been a chore due to her health related issues.  She felt for her that work was not a success because of her health, but also said that it was rewarding at times and described it as being a seven out of ten on a scale measuring success, with one being the lowest and ten being the best.  Her final answer to reasons that she did enjoy working when she did was, “It got me out of the house away from my husband and my two demon children.”

After conducting the interview with Mrs. Riddle, many of her ideas were relatable to Dr. Freud and other theorists in regards to love and work.

When we talk about love, most everyone thinks of the kind of love you share with your spouse as being the main type of love and prominently the only type of love.  “According to psychologist Elaine Hatfield and her colleagues, there are two basic types of love: compassionate love and passionate love. Compassionate love is characterized by mutual respect, attachment, affection, and trust. It usually develops out of feelings of mutual understanding and a shared respect for each other” (Cherry, 2010).  “Passionate love is characterized by intense emotions, sexual attraction, anxiety, and affection. When these intense emotions are reciprocated, people feel elated and fulfilled. Unreciprocated love leads to feelings of despondence and despair. Hatfield suggests that passionate love is transitory, usually lasting between 6 and 30 months.”

Other theorists on love say there are definitely more types of love. John Lee for example believes there are three primary styles of love. These include eros, ludos, and storge. He then goes on to explain how when these three styles of love are mixed together you get three secondary styles of love known as mania, pragma, and agape. To explain these types of love a little more, we can take a look and see how these fit into Mrs. Riddle’s life.

The relationship that Mrs. Riddle has with her husband or her ideal mate would be known as eros love. The love she received from her first boyfriend, Benny, would have been more of the ludos type of love. Her love of her friends, which she did not cover, would be seen and known as storge.  If she were to combine any two types of these loves, say eros and ludos, her love would then become an obsessive love. This is a type of love that she has never known.  Her pragma love or a combination of ludos and storge would be the realistic and practical love. This would be the kind of love she has for everyone besides her family and closest friends.  Finally the love for her family besides her spouse would be the unconditional love, or agape; a combination of eros and storge.  This would also be the type of love she understands from the God of her faith.

As Mrs. Riddle stated, she believed that love was with us from the very beginning at birth and remains with us for life.  (As the author believes, this is true in most cases.  The cases that this is not true are such as the old lady next door that hated the child.)  This is in agreement with Heinz Kohut’s self-theory, which was in total disagreement with Dr. Freud.  Kohut believed that there were three elements in developing a healthy self which would ultimately lead to a healthy loving ideal system.  These three elements were 1) mirroring, the need to be with someone similar to oneself, 2) grandiosity, the need to be understood and approved of, and 3) ideal/mentor, the need to be with someone one can admire and emulate and rely upon (Cousins, 2010). 

In regards to work, it is a difficult subject to look at since there are so many types of work.  After the discussion with Mrs. Riddle, it appeared that not only did she have her personal beliefs about work, but it was mostly based on a Biblical stand point, a stand point in which Freud (to my knowledge) never looked into.  In 2 Thessalonians, chapter 3, verse 10, the passage reads in the second half that “If a man will not work, he shall not eat” (International Bible Society, 1984).  Although Mrs. Riddle was unable to work to help her family and relied on her husband’s income, she was more than willing to do what she needed to do in order to protect her children from starvation and not having a home.

As we return to the thoughts that Dr. Sigmund Freud gave us, he believed that love and work are the cornerstones of our humanness and that love and work are all there are in life.  With this in mind, we can actually look at a few more concepts.  For instance, if we look at the idea that Mrs. Riddle’s life evolved around her family and she was unable to work because of her health, we could conclude that the cornerstone of her life was her husband and children. On second hand, if we look at the thought that she would have gone to work to care for her children had she needed to do so; we can see it all relates back to her family once again.  With this in mind, we take one last look at her ideas that we cannot live without love and that love is all there is, it returns us to the first cornerstone that Dr. Freud gave us.  The second thought that Mrs. Riddle said regarding work, was that if we do not work we do not eat nor will we have a home to live in, although Biblically based, she is in agreement with Dr. Freud.  Therefore, it is my conclusion that for Mrs. Riddle, yes love and work are all there is. These are the cornerstones of life

Saturday, Jul 10 2010 

Body Dysmorphic Disorder

How I See These in Systemic Therapy Saturday, Jul 10 2010 

Many of the thoughts and ideas that were presented by Becvar & Becvar (2009) did not really come as a surprise to me. Several of these thoughts, although not discussed as much in other theories, did not seem as foreign as they may seem at first. Much of what they try to explain as different ways of thinking in regards to some of the thoughts, really are not new or unusual, they just seem to be foreign in the aspect of what most students think therapy is truly about. If we were to look at each one of these ideas closely, we could see that they truly are not as complex as they seem. After struggling for the last week on how to write this response, I realized that not only is it more about the way we see these topics and how we would use them in family therapy, but it is also how we interpret them as well.
Using the Basic Ingredients to Create Recipes Appropriate to Each Client System
The ideas and thoughts behind even the phrase “using the basic ingredients to create recipes appropriate at each client system” can be complex if just thinking about what the theme may mean. Although we normally have not looked at such a concept, at least not in my courses previously taken, it seems simple enough when such an idea is thought through and dwelt upon for a period of time.
When thinking about the idea of creating a recipe designed as client specific, I see this as the entire family going to dinner at a restaurant. Simply put, each member of the family sstem places their order of what they would like to eat and the meal is prepared for them and brought to their table. If we looked at this in more detail and in more complexity, we can see that there are a lot of details into preparing a meal at such great lengths. For example, a few days ago my partner and I took our roommate and his grandson out for lunch at Chili’s restaurant. Now although Chili’s may not be the fanciest place to dine in town and much of their menu is probably pre-prepared, i.e. processed and prepared prior to being shipped to the restaurant frozen, it still takes some work to get these meals prepared. To make my point here, our roommate ordered a quesadilla salad, an iced tea and a beer. His grandson had crispy chicken tenders, french fries, and an iced tea. My partner ordered a jalapeño smoke house burger with French fries, an additional order of chili cheese fries, a Patron pomegranate margarita, and an iced tea. Finally, I had grilled salmon, sautéed shrimp, mashed potatoes, steamed broccoli and carrots, a strawberry mojito, and an iced tea. Now this may seem pointless to mention everything we had for lunch two days ago, but for this specific idea presented by Becvar & Becvar, it made sense.
Let us look at this as a family unit, since we all live together and are like a family. If we take each dish and break it down, it takes many different ingredients (components) to make this a proper tasting dish. If you left out one key ingredient, added the wrong ingredient, or added too much of one seasoning, it would imbalance the flavor of the dish and would not be a dish of satisfying worth. The same goes for therapy. If we as therapists, guide each client in the system in a wrong direction, i.e. misdiagnose them, give them the wrong types of treatment, choose the wrong set of homework assignments for the client, then we are making the recipe for success more like a recipe for possible disaster. For example, if I diagnosed Client N with Bipolar II Disorder and they should have been diagnosed with Narcissistic Personality Disorder, the client would not get the appropriate treatment and the family as well would suffer the consequences of the indigestible treatment.
As we look back at the ideas of ingredients being used, as a child I once misread the ingredient portion of salt for a batch of cornbread. As we were doubling the batch, it was obvious that it would go from ¼ a teaspoon to ½ a teaspoon of salt. At that time we had not discovered that I suffered from partial dyslexia and I read the teaspoon as cup, which was for the next item on the list of ingredients. The cornbread appeared to be the best cornbread that my parents had ever seen when it came out of the oven, but one bight made all the difference. If one ill ingredient is administered to a client in the system for a wrong diagnosis or even for the right diagnosis, it could have repercussions one would not like and this could actually cause more harm than good.
This concept of basic ingredients being applied to the client system is a great tool for therapists and future therapists to grasp hold of and learn from. I believe that this concept should be taught to every individual coming into the field of Marriage & family Therapy. It appears that this angle and dynamic is a key point that students, as well as the professional therapist could learn to apply in therapy sessions. With this kind of idea, and being that I had the desire when I was younger to be a chef, and having been cooking for nearly thirty years, this concept is easy for me to come be and use in therapy. I could actually see my office with an array of seasonings and spices and helping people understand some of these ideas when the circumstance was suitable to do so.
How We Each Participate In Creating Our Reality
As I tried to find various ideas from this list of possibilities, it appeared to me that this was a perfect choice to mull over and write about considering my religious view and stand point at this time in my life. The idea of creating our reality is not a new concept to me; however it is still young in my thought development. For six years my partner and I have been attending religious services at the Visalia Spiritual Awareness Center, which was a Religious Science church (now a ‘Centers for Spiritual Living®’ {CSL} congregation). In our teachings, we learn various new thought practices that not only help us in finding our perfect spiritual paths but also help us in our everyday living as well.
It is this teaching that brought the idea of creating one’s own reality to the forefront of my thinking just a few years ago. We believe in CSL that each person is on a path to their spiritual perfection and that although we have been taught that we are not perfect, we are already spiritually perfect. By creating our own reality, one that we are involved in, we actually make a difference in our own lives as well as the lives of others. If we are unable to participate in creating our reality, we are not able to participate in our own recovery. This is a much more in depth thought process than the previous one I mentioned. Trying to explain this in a few words is not something that is easy to do, but for the sake of this paper and the length of time I will sum up the concept in as few words as possible.
Through our thoughts, emotions, and feelings we each experience life. It is because of these three main factors that each individual becomes just that, an individual. With our individualistic attitudes we are able to experience our individuality and express our reactions to things such as “what in the world am I supposed to write for this paper and how is it supposed to be presented?” Through our consciousness we each make our own choices and we take action on how we choose to live life. In the practice of spiritual living that I believe in, all of this comes about through our intentions. I would not be able to pass this course, or any other class, if my intention was not focused. If all I did was think I am going to get an A, and yet I never attended classes, never read any of the reading assignments and did not complete the writing assignments or any other homework assignment, to believe that I would receive an A would be foolish of me. If my intention was to get my Master’s degree and I didn’t do the work, it would get me nowhere.
It is the same with the client. If the client comes in and takes no initiative to help in their own recovery and they choose to create a reality of issues and not want to do the work to overcome those issues, they will not see the light at the end of the tunnel. By participating in creating ones reality, the client basically follows the same pattern as my spiritual path, but on a psychological level instead of spiritual level. Again, it is easy to see myself functioning in treatment sessions with clients using this thinking. It is not new in the sense of my spiritual wholeness and balance, but it is new psychologically and I hope that it will be a method that I can use with my clients on a regular basis.
What Is Going On/ The Logic of Behavior in Context
This idea is very foreign to me, but was the one I could understand the best of the remaining thoughts. It does not make complete sense to me, but trying to think it through and understand it, I seem to make more sense of it as I go along. As I contemplate what this means to me, I think about how we as the therapists look at the entire picture in the room. We have to look at the entire scene before we can sometimes understand exactly what it is the client system is trying to tell us. Several years ago I read a book entitled He Still Moves Stones (1993) by an author named Max Lucado. In this book he describes how each of us is like an individual painting; a Monet, a Van Gough, a Renoir, a Picasso, a Baker, a Mishler, a Camarena, a Siders. Each of us are as individualistic as the next person. If we look at a painting or piece of art, we each see differences that the others do not necessarily see. In this book Max Lucado explains this same idea through the chapters. Each chapter was written about a parable in the Bible as well as some parables that are similar to Biblical ones. The first story talks about how the person walks into a small theatre, from my gathering about the size as the largest room at Brandman University’s Visalia campus. In this room were various paintings resembling these parables, all of which were always in pairs; however there were two sets of paintings that did not resemble these parable stories. One of these sets was a painting of a bruised reed while the second was of a perfect reed by the water front. The next set was of a smoldering wick and its companion piece was a wick that had its flame burning brightly. All of these paintings were just as individualistic as we are.
When we look at our clients, we need to see that their story is just as different as the client before them and the client after them. They have a story to tell and we have to be receptive to hear it and see their painting as well. When we are open to such thinking we are able to help our clients paint their first picture in the first sessions and by the time we have helped them come to closure for the reasons they came in, and maybe others as well, we will have assisted them in painting a finished portrait as well.
This concept as I think about this book that I read so many years ago, that not only was a favorite of mine, but my grandmothers as well, has opened up even more as I write this. I believe this is definitely what I believe about Marriage and Family Therapy. I see this as everything we have been learning not only in graduate courses but even in many of my undergraduate work as well. It is because of this thinking that I would be able to implement this kind of idea in therapy on a regular basis. As an artist as well, I definitely could see this as a very common course in which I would implement with my clients.
Oh and one final remark about the paintings in the book that I was speaking about. Each of these pairs of paintings showed a beginning and an ending. It was always two paintings, both on separate easels and placed back to back, not side by side. In the first one it would tell of the tragedy that had befallen the individual, such as an illness or in one case, a man who suffered from Dissociative Personality Disorder. In the second painting though, each person had been cured of their illness or disorder. The interesting part was at the end of all the stories he told, he explained that there was a pair of blank canvases with paints and brushes and that there was a sign asking you to paint your own story. This is something I could see happening in some of my sessions with some of my future clients.

Only time will tell Wednesday, Apr 7 2010 

Well, it has been sometime since I have posted, and since I now am doing this from my phone, it is a little bit more of a challenge.

Since the return of our trip to Tacoma Washington in December, life has been interesting to say the least. We now have twp additional people staying with us and our roommate and boy does this house get crowded.

I have officially begun grad school, so hopefully I can start getting some papers posted soon, after our computer gets fixed. Have 15 months till I graduate plus clinicals and my school exams to say that I know what the heck I am talking about.

We lost our computer to a really nasty virus two weeks ago and being in grad school, that so does not help me right now. Most likely will be buying one in June or July if I am unable to have someone fix this one.

Well for now I will leave at this since I need to get ready for work. Hope to hear from followers soon on ideas for as remedy for the issues at hand.

Have a great week readers!

The Four Agreements Monday, Jan 11 2010 

Could this have come at a better time? I think not. As we start this new year 2010, I chose not to make any resolutions for the new year as so many do every year. However, I have committed my life to being more responsive to greater things and ideas in my life. After completing my Bachelors degree in Psychology this last fall and getting ready to start my first semester of my graduate studies in Marriage & Family Therapy, I understand that I am in my right place at the right time in my life (even though I thought I would have been here within the first ten years out of high school, that would have been ten years ago now.) After reading the notes, I think that I may just need to go ahead and read the entire book. I knew that things have been off in my life for a few months. As I started to look into this new year, I made a commitment to better myself by taking time for me for a change and going on a Vision Quest. This quest is being done to rediscover those things in my life that I feel have been so vital to me, yet I lost them some where along the way. Part of this quest was to search my soul and find out why I lost my desire for music, understanding that music has been such an influential part of my being for the last 23 years. Somehow, I felt that music didn’t matter any more. I quit listening to my collection, and rarely listen to the radio. I also quit writing various musical pieces. This is so not the me I was used to.

In the first agreement we learn that we need to be impeccable with our word. What I found the most revealing is that the word ‘sin’ means to err or miss the mark. How many times have we all “sinned?” In the five things we were asked to look at that needs some work in our lives my first three had to do with this agreement; belittling myself as well as belittling others and then gossiping, .sniping, and nit picking about others as well. I always remember the story about nit picking from a sermon at church I once heard. The minister was saying that we as a people, have become like monkeys. See monkeys go around cleaning each other and pick (clean) the nits off of each other. When we see the issues of others that we feel that they should not experience, i.e. smoking, overeating, over weight, etc., we have a tendency to NIT pick about their problems and avoid our own. If you cannot keep your own house clean, how are you going to be able to clean someone elses?

In the second agreement, Ruiz says that we need not to take anything personally. This is a bad habit of mine that I have dealt with all my life. “You’re no good at that.” “You’ll never be any good at that.” I grew up with those words from one of my grandmothers most of my life. So this is one area that I have struggled with over the years. Because of this I see a mantra that will be at my desk to read every day when I am studying, on the computer, or whatever may put me at my desk:

“I’m totally independent of the good or bad opinion of others. I’m totally independent of the good or bad opinion of others.”

Because of this I have thought of myself as not great at anything, although I know that I am good at some things. I know that I can sing, and that I am an excellent singer/ performer, however I never have felt that I am a Josh Groban or Povarotti. If I work at it, I know I can be as good as they are. Recently I started taking up art. I know that I am no Picasso. I AM ME. I AM MICHAEL CRILLY. I do not have to be Pablo Picasso to be an artist. I do my own style and ideas of what art is. I may not be as good as he was, but my art is my art ind that is all that matters. As I have on my profile on gaia.com (formerly Zaadz), “I am beautiful. I am a Phoenix. I AM ME.”  I know that I have constantly battled this area in my life, thinking that no matter what I did I was failure or having unworthy feelings toward myself. No More!

“I’m totally independent of the good or bad opinion of others. I’m totally independent of the good or bad opinion of others.” And “I am totally independent of the good or bad opinion of myself.”

In the third agreement, Don’t make assumptions, I found that although I thought I had stopped assuming anything, I was just kidding myself. If you actually take the word apart, assume, it gives three words; ass u me. This makes an ass out of u and me. I am sorry but I was not created to be an ass and neither was anyone else in this world. We were all created in the likeness of the Divine. God was not a donkey and neither are we. One of my worst memories was of treating one of my former best friends like an ass. As a music major, originally a vocal teaching major, I would help my friends by teaching them how to sing. One day when my best friend was singing I told him that he sounded like a dying mule and it was making my ears bleed. I was only joking about it, but it hurt his feelings so much that he never sang in front of me again, even at church services. I made an ass out of myself more so than anyone ever assuming does.

Finally in the fourth agreement, Don Miguel says “Always Do Your Best.” Last year me and my partner’s roommate had gone to “church” one Sunday when neither of us was feeling up to par. The minister is one of our regular prayer practitioners and spoke on Our Best. She said that no matter what you are doing, if it is your best no one can ask for any more than that. Since then I have focused my life on doing my best. If I go out and look for a job and only turn in five resumes a month and that is my best, I cannot ask for anything more. If my friend says that five resumes is not my best and that I need to turn in at least ten a day, who is to say that is my best. It may be their best, but if my health prevents me from getting up one morning or going to every place I am qualified to apply, than I can only do MY BEST.

In conclusion, I know that I will be placing many of the notes from todays reading in plain sight to remind me of the four agreements and how to utilize them for my best good.

If you are interested in knowing more, or soul searching your own self, you might visit http://www.philosophersnotes.com or http://www.gaia.com!

Vacation Time Sunday, Dec 6 2009 

So for the past four weeks, I have pretty much been away from the computer. Therefore I have not had any time really to sit down and take the time to write up what has been going on in my world. In the next few days I will get back on here and write up my story about our (me and my husband’s) trip to Orange County for the International Court System Orange County chapter’s fund raiser and also about our three week, sick 2/3’s of the time, vacation to Tacoma, Washington to see my mother-in-law.
Until my next post, Have a great day. Live life to the fullest for t flies by too quickly!
Michael

Black Market Medicines Thursday, Aug 20 2009 

So I am currently working on research and writing a paper for an Independent study course and one of the topics that came up was “black market medications.”

I have seriously been thinking about this for the past few days and it has me disturbed to think that our society has to find pills to take for just about everything, and no less can get them from companies that do not require you to have a prescription.

Say for instance, you think you have depression because you are feeling a little blue or melancholy.  All you have to do now days is jusmp online, find an online pharmacy that does not require a prescription and have a method of payment, and vuala. Your pills are in the mail.  But what if, you choose a pill, such as Pamelor, what if you have a serious medical condition that you do not know about?  This could possibly have a harmful side effect and make you very sick or even possibly kill you.  As a student of psychology, knowing that we as psychologists are not able to prescribe medications, it is my recommendation that you speak with your medical doctor first before you try and just order your pills online.

I understand that we are all trying to skrimp and save as much as we can in these hard economic times, but, be realistic.  This is your health and life we are talking about.  No pill is worth taking if it can cause more harm and damage than what it is intended for.

So my advice to you, if you are reading this, please, do not order pills from online unless you know the source, such as CVS Pharmacy or any other major pharmacy.  Black market medications can be harmful if not vital to your health.  For your sake, please take to your medical doctor about any medications you are currently taking, any medications that you feel might benefit you and any medical problems that you are experiencing.  Your doctor is their for your health.  Let them help you out.

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