1.1 Introduction

A qualitative type research has been chosen as opposed to a quantitative one due to the very nature that this report for it revolves around the inner experiences of an individual's human suffering. Hence, it only seems appropriate to begin the chapter with the introduction of the subject of this report rather than the typical theoretical review for he is at the center of it all. He is where this report originated from.

This section shall also brings forth and explain the various steps taken throughout the study. These includes introducing the subject of this case study, the particulars regarding the objectives, as well as the methods and the surrounding circumstances applied as the foundation from which to proceed.

1.2 Subject

The subject of this case study is a male client, age 51. He first came to the Montreal General Hospital Human Sexuality Unit and was interviewed by the unit team members. The client was then assigned to myself to meet the objectives of my internship at the hospital in September of 1995. Physically, the subject measured close to 5 feet 11 inches tall, weighing approximately 165 pounds with a fairly broad frame. He grew up in a moderately large family which included a doting mother, a father stricken with multiple sclerosis and confined to a wheelchair. His siblings consist of 5 brothers, he being the youngest of the family with ten years difference between himself and the youngest of his five brothers.

Most of his childhood was spent by his mother's side, watching her going about her daily activities and as she worked. She was a dress maker working out of her basement. He is presently employed as an administrative position. The subject has a high-school leaving certificate that was furthered by other courses and a very well developed talent in his particular field of work. He has always had great ability when it came to creating projects that require good perceptual knowledge and being handy with his hands. His hobbies include handiwork, building train sets, model airplanes, drawing, etc.

He describes his social situation as lacking any meaningful friendships and he has always found it difficult to make friends and establish significant relationships. He is presently married to his wife of 25 years, 15 of which did not involve any form of sexual contact. He is the father of three children that are presently young adults, but still reside at home.

In terms of attitudes and values, the subject does not consider himself as being religious but as a very spiritual being. He follows an inner moral code which involves a great emphasis on caring, loyalty, honesty, not to hurt other people's feeling, being kind and being a generally very reliable person. This also includes a history where, growing up sex was considered a taboo subject, and masturbation, although everyone did it, was a shameful and a guilt ridden practice.

He can be described as an individual who is emotionally fragile, timid, with a very low sense of self-esteem, but can put up a strong front. This is accompanied by a great desire to be liked (or rather loved and desired) and to please others.

Upon entering therapy the client described the DSM-IV criteria for transvestic fetishism including gender dysphoria.

1.3 Objectives

The aim of this therapeutic intervention report is to follow the subject suffering from transvestic fetishism during his therapeutic journey. Throughout the therapy, existential theory, procedures and concepts shall be used as a basis to explore, interpret and understand the subject's situation while demonstrating any progress towards a better sense of being. This is according to the terms and ideals of existentialism as a therapeutic approach. This, in hopes of gaining significant qualitative data regarding transvestic fetishism as a phenomenon and recognizing existentialism as a viable alternative in treating clients with such a disorder.

Stated above are the objectives set out in this specific report, however, there are other objectives that exist, those pertaining to those involved in the therapeutic process itself. These take into consideration the goals set forth for the subject as well as the therapist.

The objectives associated to a report of this nature is restricted to the emotional domain. That is to say, when involved in a therapeutic process we are dealing with a very intimate and emotional area of the individual. The whole process takes time. A change that is to occur on an internal level in one's attitudes cannot take place within a short preset period of time. It is a life change that hits at the heart of our being, our values, and beliefs.

On the most general level, the object of such a therapy process is change. Change in its true form transforms the interior and the way of living rather than the behavior or the way of expressing oneself in public. Change must first take place on the inside, in the attitudes and in the subjective, there where resides in large part the person. Once this occurs the change has been integrated on a more global level.

The goal of sex therapy can be reduced to rendering an individual functional. It can also simply be the achievement of sexual pleasure. However, Bureau (1994) suggests that the general objective consists in helping the person in attaining a maximum sense of his/her identity. That is:

1. To be comfortable in one's sexualized and erotic body.

2. To recognize oneself as a being in the process of becoming able to act, therefore free and responsible for their choices.

3. To accept being significant to others.

It is once he/she has reached their ideal sense of identity that the person becomes their own source of vitality and satisfaction.

It is from the importance of the here and now, the experience and contact with oneself that we derive the goal of therapy, which is to help the individual integrate their experience, which will allow them to be authentic, self-actualized and assume their becoming.

On the therapist's part, it is the search to understanding the client as being in his/her world that is their general goal. The goal of therapy is not to cure but to understand the Dasein (way-of-being in the world) of the malaise the client is experiencing, their immediate subjective experience. It is important to note that this understanding does not come from any particular theory since everyone's experience is a unique one. Hence, it becomes obvious that the techniques and strategies used to attain this understanding are secondary to the actual understanding.

More specifically, the aim of therapy involves:

- The client accepting the existential givens of his/her being in the world (finitude, solitude, freedom, corporeality, and ability to act).

- Having faith in oneself which implies taking what you are, as you are, and accepting it as is. It is to rely on yourself, to take what you are and work with it.

- That the client Be there, Be present. The therapist aims to receive, encourage and give rise to this sort of authentic presence within the client.

- Developing a therapeutic alliance.

- Encouraging that the client (and therapist) be as subjective and authentic as possible.

- Broadening of the client's consciousness in order to develop vitality.

- Attaining a level of critical communication, a very intimate and honest level of communication that concentrates on the here and now of the emotional experience.

- Experiencing the here and now.

- Creating a sense or purpose to living.

- Achieving a high level of concern by the therapist for the client as well as by the client for him/herself.

- Being committed. That is, the therapist be committed to himself (fully present), to the client (to his being and encourages the enlightened side within the client), to the clients family, society and to the unknown and not understood. In the alliance between the therapist and the client, both must come to be mutually committed.

- Assume his total and complete masculine identity.

- Face the existential givens of existence and negotiate the anxiety they incur. That is, to become responsible by assuming his masculinity, his actions, ... leading to a sense of freedom, to accept his limitations in beauty, body, and so forth, that he confront his solitude and in turn realize his individuality and uniqueness.

- Ultimately, to no longer feel this need to cross-dress as a sexual outlet as well as a way of seeking warmth, comfort and security. That he could feel this and be fulfilled from within rather than from some external representation.

1.4 Environment

The physical organization of these encounters, the atmosphere of the surroundings where they took place, the way of being of the therapist, all represents important factors affecting a therapeutic process. These sessions (of 50 minutes long) took place twice weekly over a period of 8 months in an office of the Montreal General Hospital within the Birks Mental Health Building. The office itself was approximately 10 by 12 feet with good lighting and generally quiet except for the occasional passer-by and murmurs. The environment would be described as bland but intimate, and conducive to a therapeutic relationship of trust and understanding.

The therapeutic intervention, as mentioned earlier, revolved around existentialism as a mode of therapy. Thus, it could be classified as a pre-existing and established sexually oriented therapeutic intervention method.

1.5 Agent

The therapeutic intervention was conducted by only one individual. She used an existential therapeutic approach and had 14 months of experience in the area as part of her internship at the Montreal General Hospital. This within the context of the Master's program in Sexology in Counseling at the University of Quebec in Montreal. Her past includes a Bachelor's degree in Psychology as well. Throughout the entire therapeutic intervention process the therapist was closely followed, (on a weekly bases) by a qualified supervisor teaching at the University of Quebec in Montreal.

Materials used within the context of the therapeutic procedure were fairly limited. They simply consisted of an office with relatively comfortable seats, a tape recorder that recorded every session that was later transcribed and used as verbatim. This information was kept on file to later be used to provide direct quotes throughout the report for purpose of information analysis and monitoring subject progress.

1.6 Techniques and strategies

The existential therapist does not try to bring forth any logical or historical explanations to the client's problems. To do this is to be limited to one's rational rather than the total person. The experience is always one of a unique individual, an I that is different from all others.

Over all, what can loosely be referred to as techniques or strategies, seeks to create the unity of the individual, an understanding of their experience, a sense of continuity and becoming.

The therapist gains his/her understanding by situating the difficulties within their client's personal evolution. He/she tries to create conditions that permit them to be as authentic as possible and truly contact their experience in the moment. All knowledge that we have of a person must be brought back to their present existence. This revealed during the interaction with the therapist who is trying to understand him/her. We can say that all the techniques used must be subordinate to this search to understand the client as being in his/her world.

Everything that a therapist can discover about their client must come from their client. This even though the client may not really know how his/her internal universe is organized, what their true meaning or purpose is.

It is mainly through the therapist's ability to empathize that the discovery of one's internal universe can take place. This demands that the therapist be totally available, with complete personal transparence, the intention to understand and an ability to capture the meanings expressed by the client within a context.

The therapist reformulates what he/she understood of their universe to the client. When properly done it receives immediate agreement from the client.

The therapist also asks explicatory questions that aim to clarify or develop that which the client has communicated on.

The behaviors, imitations, and emotional reactions during the interview are sometimes pointed out to the client as he/she clarifies the sense of his/her experience.

As stated earlier, the client's primary duty throughout therapy is to Be there, to Be present. The therapist's primary duty is to receive, encourage and give rise to this sort of authentic presence within the client, a presence of concern for their life. This is accomplished through the complete presence of the therapist.

In therapy, the concern for presence leads to developing the therapeutic alliance. It is a common endeavor based on the authentic encounter between two people: the therapist and the client. This is accomplished by the therapist applying and involving him/herself to the fullest extent (in thoughts, emotions, and imagination) in this alliance. The client provides the content, and the therapist sees to the process, the client's means of handling the content. The therapist is the client's companion of existence, who intervenes in order to identify and weaken the client's resistance to being alive, conscious and responsible.

Due to this presence and alliance, the therapist tries to contact the client's subjectivity, using every means at his/her disposal.

This is done by the therapist renouncing and fighting all temptation to objectify the client, or to use a diagnosis that could possibly fragment or manipulate the client by conditioning. The therapist also tries to prevent the client from treating him/herself as an object that can be manipulated from the outside. The client is called upon to plunge within him/herself, that is, to be as fully subjective as possible, while refraining from treating him/herself as an object, disconnected from his/her experience, emotions, needs and intentions.

Authenticity by the therapist is to help the client be more subjective and conscious. Being authentic is being real, by making as congruent as possible the circumstances of one's internal experience and the experience within one's body language, one's role and one's communication with others.

Through paralleling, a way of translating our frame of reference in the task of therapeutic intervention, it is possible to bring the client to be subjective and authentic. It is through this that the client will find their developmental path. It is following or not following the client, that is, it is the process by which the therapist can choose to follow the theme, emotion, frame of reference,... that the client has chosen. He/she can also diverge from it if the client does not seem to be getting anywhere.

Concern is a feeling of caring for the other, it is the therapists concern for the client in therapy. Concern is one of the conditions of experiencing (which itself encourages complete presence). The therapist's concern for the client is a method to shed light onto the path that should be followed within the therapeutic process.

The use of critical communication, the fourth form or level of communication is an indication of the level of presence.

Commitment is a way of assuming a decisive orientation, or direction for the self, life and the future. It is a prerequisite to getting to the truth. It is a commitment to working for a cause and to putting into action one's energy to the service of an idea.

1.7 Evaluation procedures

The evaluation regarding the subject's journey towards therapeutic progress, illustrated through existential concepts and theories (over a period of 8 months) shall take place throughout the report. That is, as the theory is presented it shall be further illustrated in the form of verbatim and/or explanations as it applies to the subject of the case study.

Over the span of the study a series of processes and content is to be explored that relates to the existential therapeutic approach. Direct quotes taken from the therapy sessions shall be used to illustrate any therapeutic gains. It goes without saying, that due to the scope of such a report, much valuable information must be eliminated. This, in hopes of meeting the report requirements while maintaining a level of consistency and interest.