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Case Study Report

DeLante Fludd

School of Nursing and Health Professions, Trinity Washington University

COUN 640: Internship I

Dr. Kia James

March 21st, 2023

CLIENT: S. K. Counselor Trainee: DeLante Fludd

Demographic Background:
S. K. is a 14 year old transmasculine individual. They use They/He pronouns. They live with

their mom, dad and brother (12). S. K. is of mixed background with their mother being of

Hispanic origin and their father being White. S. K. is currently in the eighth grade and is

beginning to explore the transition to high school. They have a supportive friend group that they

are able to connect with and share their feelings of gender identity. S. K. identified as having an

ACE score of 1. They are active in track and field and enjoy the creative arts. They also enjoy

skating in their free time.

INITIAL CLINICAL IMPRESSION:

average build and appear to be an appropriate weight for their age. S. K. is a bit shy at times and

expresses they are typically shy when meeting new people but once they feel comfortable, they

open up just fine. There is some hesitation in expressing their feelings and home life. They have

a great understanding of gender identity and sexual orientation. Their use of vocabulary is also

age appropriate and though they tend to struggle to find the right words to express themselves.

REASON FOR REFERRAL:

S. K. was referred to counseling through involvement in Child and Family Services Agency

(CFSA) involvement. The family is receiving support from CFSA due to issues of parental abuse
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and domestic violence occurring in the home. The client was referred to discuss issues related to

gender identity and issues in the home. S. K. mentioned their parents lack of understanding

regarding their gender identity and would like additional support for exploring and building their

self-confidence in expressing themselves.

Presenting Concern(s):

S. K. was a bit apprehensive to begin therapy but wants an outlet to discuss things that they do

not feel comfortable discussing with their parents. The major concern of the client was finding

support for gender identity and being able to express this to their parents effectively. S. K.

mentioned family members sometimes using homophobic and transphobic ideology and they

often have to go above and beyond to correct family members. There are also concerns regarding

behavior and respectfully educating others of their gender identity. The client may act out when

they are misgendered or withdraw when they do not feel safe.

GOALS, TREATMENT PLAN & PROGRESS:

The major goal for S. K. is to get additional support in exploring their gender identity and

expressing this to their parents and family. The goal is to provide the client with a safe space to

explore their home life and ensure safety needs are met. As the client has a lot of issues going on,

the approach is to focus on those safety needs and report appropriately when concerns are raised.

Attendance to sessions is spotty as the primary caretakers often lack communication with each

other. Sessions are scheduled weekly but it seems sessions occur bi-weekly at most often.

In the initial session, the client felt nervous to openly talk and would sometimes get

frustrated when they could not answer questions. We have begun using crochet in therapy as a
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way of calming those nerves and taking the focus away from having to make consistent direct

eye contact. After the implementation of crocheting during the sessions, the client has more ease

in talking about things that are going on in their life. Occasionally, the clinician will speak with

the mother following the sessions where concerns have been raised. The mother has expressed

that she feels the client is still not fully opening up and that they are having a hard time

managing stress.

S. K. has revealed that they have expressed to their medical provider interest in medically

transitioning from Female to Male. They are more confident in their ability to express their

gender identity and show great progress towards supporting their parent’s understanding of this

change. The new focus is to support the client in understanding the positive and negative aspects

of medically transitioning. In addition, as the client will be going from middle school to high

school, the client is a bit anxious or concerned with this transition as well. A major focus of the

sessions will be to work on addressing and eliminating some of those fears for transitioning to

high school.

CASE CONCEPTUALIZATION (FORMULATION)

In working with S. K., a Gestalt approach is utilized. Gestalt therapy focuses on the

complete whole of an organism (Perls, 1992). Perls saw Gestalt as a look at the client as an entire

organism. The need for therapy occurs when the gestalt or the whole, is not complete. Everything

in the organism relies on each other. The experiences of the individual come together to form a

completeness. We are constantly learning and evolving which requires change. If change is not

welcome, we become stuck or remain incomplete which creates an imbalance. One of the major

goals is to continue to transform.

S. K. has many parts that are surfacing that need to be connected and tied together. These

parts are gender identity, issues at home, relationships with others, and more. The goal is to help

them identify where the holes exist and fill those holes to bring about completeness to the whole.

In focusing on the gender identity aspect, S. K. has a strong working knowledge of their gender

identity but only focuses on their limited view and are unable to find the view of others.

Additionally, the incongruence between their perceived gender and assigned gender create a hole

in their gender identity. While this will likely be incomplete until the client has transitioned,

there are steps that we could take to get to a point of filling in that hole. The therapeutic

relationship relies on strengthening the client’s understanding of their gender identity and how it

relates and interacts with their experienced world.

Moving forward, one of the goals is to focus on the comorbidity of anxiety or depression

with the primary diagnosis of gender dysphoria. The mother of the client has noted a lack of

interest in activities that in the past brought joy and the client has indicated a persistent sleep

disturbance. These issues show that the incompleteness and constant worry regarding their

gender is causing an impact on their overall functioning. S. K. has indicated more agitation than

usual at others and finds it difficult to remove themselves from the situation.

Reflective Summary:

This was one of the first times that I was able to see progress in a client with consistent

attendance. This client has grown stronger already in expressing their emotions and feelings.

While this is the case, there is still work to be done. We will continue to tap into the client’s

strengths and utilize those to overcome the obstacles that arise for the client. The major focus

will be to bring some peace where the client is in order to help them get to where they want to
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go. S. K. has a lot of things working against them and requires persistent attention and support in

order to meet their goals. As a clinician, I would like to lean more into Gestalt therapy and find

ways to integrate this more fully into the sessions. One thing I would like to incorporate is

dreamwork as outlined by Perls. The focus here is a bit different from that of psychoanalytic

dream work. Gestalt dream work brings the dream to life and identifies the meaning as it relates

to the present. It puts the client in the dream as it is now and I find that interesting and would like

to explore this with S.K.

References
Perls, F. S. (1992). Gestalt Therapy Verbatim. The Gestalt Journal Press