Notes on Gender Role Transition

By Anne Vitale Ph.D.

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T NOTE #2

The Intake Appointment

March 7, 1996

In T Note #1 I wrote about the machinations, or to put it more poetically, the dance that goes on between a potential gender client and a therapist. This time I'll concentrate more on the specifics of the intake appointment.

As you may recall, I said there is a large amount of sizing up that goes on by both parties during the first appointment. This is as it should be: both parties have a lot at stake in establishing a favorable therapeutic relationship. The client is dealing with an extremely important and personal problem. The wrong therapist can set an individual back for years. Meanwhile, the therapist is deciding whether or not to commit to the clearly defined professional, legal, and ethical responsibilities that are inherent in accepting any client.

Although the routine varies from therapist to therapist, all prospective clients can expect the intake appointment to be very structured. The reason for the structure is that along with accessing the presenting problem, there is a certain amount of legal, ethical, and plain ol' business for the therapist to attend to. The therapist needs to know as much about the prospective client as possible in that first hour. Furthermore, she has to do this while showing the client that she has the willingness and the capacity to help resolve the problem. To save some time, some therapists ask that the client fill out a biographical form before coming to the office. Others, such as myself, prefer to ask for biographical data directly. I consider it part of a standard mental status exam.

No matter what the presenting problem, the therapist should provide as safe a place as possible for the individual to work. Obviously, only a very small portion of what is really going on with the client will come out in the first session. However, an experienced therapist should be able, in that short time, to deduce the extent and kind of psychotherapeutic work required.

Because of the extremely private and frightening nature of gender issues, gender clients tend to be extraordinarily cautious. As a way of both honoring the individual's caution and easing the situation, I start the intake session by asking how the individual got my name. If it was from a former gender client, my writings, or an ad I have placed in a gender newsletter, I learn immediately that I am dealing with a gender issue and direct the interview accordingly. For example, I frame my inquiries in such a way as to reflect my knowledge of gender and crossdressing issues. This reassures the individual in two ways. First, the individual can immediately tell that she or he is not going to be taken for some sort of kook or, even worse, considered crazy. Second, if I do my job well, the individual will start to gain a sense of confidence in me at a very critical stage of the therapeutic relationship. Confidence in the abilities of the therapist is critical in all therapeutic relationships. When dealing with gender identity issues confidence is crucial. It can literally be the difference between life and death if matters should eventually get to that level of difficulty.

As the intake hour nears its end, if I feel that the client and I are not a therapeutic match I will tell the individual outright, giving them several referrals. However, if I feel that I can work with the individual I gradually begin to volunteer more information about my professional qualifications. I discuss my therapeutic orientation and my qualifications as a gender specialist. This also includes a short description of what I expect from my clients. I let the individual know that I take a case management approach to my gender work and describe my professional association with other mental and medical health professionals that eventually may become involved in the healing process. If the client agrees to work with me, the intake session is closed with the discussion of several standard disclosure forms. I require each person to read and sign a form describing the Limits of Confidentiality and a form describing my general business practices. A third statement, if the situation calls for it, consists of my treatment guidelines.

Although the laws regarding Confidentiality vary from state to state, my Confidentiality form states that the therapist is prohibited, both ethically and legally, from disclosing any information the client reveals to the therapist. This includes the very fact that the individual is in therapy. Because there are some very important legal exceptions to the laws regarding privilege in California, I take this time to explain them. These exceptions come into play if a client makes a serious threat of suicide or physical violence to others. Suspected or confirmed child abuse and confirmed elder abuse are two other disclosures the therapist is required by law to report to the proper agencies. My general business form is typical in that it contains my fee and payment expectations, insurance repayment policy, telephone calls, etc.

With business matters completed, and agreement to continue working together in place, it remains only to set a regular appointment schedule. The next time the client and the therapist meet, the situation is far more relaxed for both individuals and the real work of resolving the client's gender issues can begin.

(A substantial portion of this Note originally appeared in issue Number 75 of Cross Talk under the title of Dances With Therapists Part 2 )

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Copyright, 1996 by Anne Vitale, Ph.D. Dr. Vitale is a Licensed Psychologist specializing in gender related issues. Her office is located at 610 D Street, San Rafael CA 94901, (415) 456-4452. This Note may be reprinted in any non-profit organization's newsletter if Dr. Vitale's name and address appears with it. Other publications must obtain written permission from Dr. Vitale. A copy of any reprints must be sent to Dr. Vitale.