An undermined therapeutic alliance: A case study

Abstract

Seeking help and assistance can prove to be a frustrating experience for intersex individuals: physicians and psychologists can be misinformed about variations of sex characteristics (VSC) and their practice may have a detrimental effect on the physical and psychological wellbeing of individuals with VSC. This paper focuses on how previous negative experiences, such as early genital cosmetic surgery and unaware clinical management, could negatively affect psychotherapeutic relationships. Its principal aims are to: 1) identify which elements in clinical management of VSC may cause difficulties in building a therapeutic alliance and 2) identify which elements may promote the construction and reinforcement of the therapeutic alliance, even when a patient’s trust has been damaged by previous negative experiences. In order to explore the psychotherapeutic process with specific regard to the building of the therapeutic alliance, we report a case study whose subject is a 32-year-old man who sought legal advice for his sex reassignment process and began a brief supportive psychotherapeutic treatment. Roberto, the subject of this study, was born with VSC, was assigned the female gender and underwent genital surgery at birth. In his early childhood, he developed a male gender identity. Whenever Roberto reflected on the genital surgery that he had undergone at birth, anger and frustration pervaded his psychotherapy sessions and made it difficult to build a therapeutic alliance. However, it was possible to support Roberto in redirecting these negative affects, helping him to process them, build a therapeutic alliance, and benefit from a positive and trusting therapeutic relationship.