This week we split up into small groups to discuss case studies in a simulation of a peer-supervision group.
The first case study I presented was a male in his mid-forties that had been suffering from a lack of direction and had several signs of being in the midst of a mid-life crisis. I related to the client a lot, which mad empathic understanding quite straightforward, but I was careful not to over-identify too much, and second-guess how the client may actually feel about certain things. We built a rapport quickly, but I feel we moved from one modality (Cognitive Behavioural Therapy) when discussing his present situation and ways to combat his core beliefs to another (Psychodynamic) when deeply exploring his past in too haphazard a fashion. However, the issue I brought to supervision was that I did not know how to deal with him showing me some photographs of his wife and children. He was telling me how upset he’d be if he and his wife split up as he’d barely ever see his kids, and it triggered a feeling of deep loss inside me, as well as a confusing feeling of being very tongue-tied – I didn’t know what to say and blurted out something about how his kids looked beautiful, and really happy. I said this just to fill the uncomfortable silence. For reference, I don’t usually feel discomfort in silence.
We talked about the client and the problem for a while, and both Meredith and Rosalina had great suggestions for me. The conclusion that we came to was that I needed to work out which modality would best suit the client and his needs; I needed to be more specific in terms of which theory I was using with the client, as this would help add structure and measurability to the therapeutic relationship.
Our tutor advised me on how to deal with the photograph situation. I felt supported in this close discussion with my tutor, and that my limited knowledge of how to deal with the situation was helped greatly by her suggestions; I felt as if she were passing on some of her advanced skills in dealing with such instances on to me. In the counselling session, when the client showed me the pictures I said “oh, they are really happy looking kids, they have beautiful big smiles” – and our tutor’s suggestion was that in future I should thank him for trusting me enough to show me the pictures, and comment to the effect of “they must really mean a lot to you, I can see they are very dear to you”. Her reasons for suggesting such actions made sense in relation to Person-centred counselling theory, in that it is all about the client – my reaction to them was not important, but the fact that he felt safe enough to show me something so special to him was the actual important part. Reflecting on those insights now makes me see that I should not have commented on the contents of the photograph, but commented on how much the people in the photograph clearly mean to him, and internally acknowledged how much trust he feels to show me, how much trust we have in our relationship. It was also suggested that I consider spending an hour in personal counselling to resolve the issue of why the photographs triggered such a confused reaction in me.
The next problem we discussed in our group was Meredith’s first client, an older lady with a history of sexual abuse. Meredith’s description of the client and their relationship was full of little pertinent details, which really helped me get a very clear picture of her way of being. Meredith presented confusion about how to deal with the sexual abuse in terms of keeping everyone safe, and we advised her to do a risk assessment on the client to determine the likelihood of a possible instance of self-harm. The relationship is clearly in good stead with lots of trust and empathy, as well as strong, respectful boundaries, but due to Meredith’s lack of training, the client’s sexual abuse and the related trauma may be beyond her limit of proficiency, so we advised her to signpost the client on to a counsellor that specialises in sexual trauma.
It also may be a good idea for Meredith to make sure her training is up to date with regards to her own personal safety so she can get out of dangerous situations. While this client was not violent or aggressive to Meredith, she had been aggressive to other healthcare professionals in the past. Meredith also said she was having problems understanding thick or foreign accents, we suggested it may be a good idea for her to get clients to write things down if she’s unsure, or take some assertiveness training so she feels empowered to ask them to repeat things.
As Rosalina didn’t have an issue with a client at that particular time, we went over Meredith’s second problem, which was that she felt stuck with a client and was unsure of which way to go next. Again, she outlined the client and the problem really well, which was a middle-aged man that had recently lost his Dad and had become extremely agoraphobic, and she felt he needed to process his grief but he was really resistant to it. We discussed the possibility of using CBT to combat the agoraphobia, but decided that it probably wouldn’t be effective while he was still in the midst of grief. We collaboratively decided to stick with person centred for a couple more sessions, see if Meredith could start the process of him coming to terms with the loss of his loved one, but if that fails, she should signpost him on to a dedicated grief service.
We also suggested some personal counselling for Meredith, as discussing grief and the need to process it brought up some unexpected feelings in her. It’s very important to resolve personal issues so they don’t trigger unwanted reactions in you in the middle of a session with a client.
I have added the insight I gained from the case discussion on the CPCAB presentation sheets I used to get a rough outline of this client and the problem I wished to bring to supervision. These can be found in last week’s Reflective Diary. My input into others’ case studies can be found below. It is a picture of the notes I made in the discussions that I gave to the others in the group.