Case Study 1 – ‘Mary Smith’ Client Pseudonym/s – Mary Smith Details – Female Age

April 17, 2019 Critical Thinking

Case Study 1 – ‘Mary Smith’

Client Pseudonym/s – Mary Smith

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Details – Female Age(s) – 8 years old
Ethnicity – Maori
Setting – Sessions were held in a private room at her school

Contact Record – 9 sessions

Current Case Status – Completed

Referral –
Mary was referred to counselling by her mother. The mother and father of Mary had separated due to family violence from the father several months prior. The mother expressed concern regarding Mary that particularly during the weekend custody visits she was being exposed to inappropriate behaviours from the father. Especially concerning Mary sleeping in her father’s bed alone with him, him showering her and abusive language being used around her. She also had some concerns that Mary had become more clingy with her and increasingly not sleeping in her own bed but with her mother instead. There was also some concern that she was not doing as well at school as she was before the issues with her father started.

Mary presented as a very talkative intelligent girl always willing to engage in our sessions. She had previously completed a family violence children’s course with another provider that involved various art during the sessions. Because of this previous positive experience, Mary was keen to incorporate ‘fun’ art/learning based activities into our sessions of her choice including drawing, colouring in and word/thinking games, e.g. dot to dot, crossword puzzles. Her understanding of why she was to attend our sessions w as that her, “Dad says bad things” when she visits him. I was asked by her mother to see Mary at her school where she felt Mary would feel most comfortable rather than at our agency office and it would be least disruptive to her emotionally as well.

Assessment and Planning
Formulation –
I had initial safety concerns for Mary regarding the alleged reports by both her mother and teacher surrounding her visits to her father, but I wanted to keep an open non-judgemental mind in my sessions to adequately assist Mary . My goal was to build rapport with Mary during our sessions and let her talk about whatever she wanted during the sessions, then re-assess my concerns based on what she would tell me at the time if any at all. I did not want to ‘lead’ her in conversation content but would make broad general enquiries instead during her conversation with me allowing her to share what she was comfortable too, understanding it would be dependent on how safe she felt. I intended to use creative art-based activities in our sessions as requested by Mary to help her engage and stay engaged. This non-threatening, fun approach would further help her to feel comfortable to speak freely and for me to work with her narratively as required.

This plan was successful as Mary engaged in talking freely about her life in general, being the chatty young girl that she was, which occurred from our second session together once we were alone, and, “Had fun” with an activity of her choice for the session while we talked. I never found any difficulty in engaging with Mary in all our sessions together due to her lively personality. She was always very expressive with facial expression, tones of voice and body language when she spoke. When she was happy, she would be boisterous, more confident in her tone of voice and sit up straighter often swinging her legs as she spoke. However, when she was talking about something that upset her she would have a softer voice, her body slouched somewhat, and she used less eye contact , instead focussing more intently on her art/creative activities while she spoke. Bec ause she enjoyed creative activities, she would take home her drawing or activity sheets after each session to show her whanau. This ongoing communication assisted her to learn the skill of being able to openly express what she is thinking and feeling to important people in her life. She effectively engaged in narrative therapy drawing when encouraged to do so.
On the occasion’s Mary engaged in narrative therapy, I would ask her to draw how she was feeling about whatever concern or fear she had. She would talk about her feelings and describe what she was drawing as she did. She would tell me what each thing of significance was she had drawn and what it meant to her as I inquisitively enquired. Once this was completed, I would then ask her to draw a new picture showing me what she would like things to be like without the fears or concerns of the previous picture she had drawn. We would then discuss the new items of significance and how they would make her feel if things changed to this new way. We would then consider what things she could accomplish and help her plan how to do this. She would willingly consent for me to talk to her mum about any ideas and her new plan forward so her mum could help her achieve this.

On occasion’s when a situation where Mary raised a care or protection concern, I would talk openly with her about my need to speak to her mum about it to help her stay safe, which she always agreed to readily. I would talk about what I would tell her mum and why. On occasion’s, she would ask questions to help her understand or address any fears she had. On one particular ti me, she asked me if her mum was going to ‘get into trouble’ when she disclosed to me about a concerning incident that occurred where her mother and grandmother had had a verbal fight together, and they both had hold of each of Mary’s arms pulling at her, while they argued over the top of her. She told me this frightened her while she showed me a small bruise on one of her upper arms that she said occurred from that incident. In answer to her query, I explained that my role was also to help her mum, grandma and dad be the best parents they can be for her , and that the reason for talking about these things further was to not to get anyone into ‘trouble’, but to help everyone be happier and safe together. She accepted this as I would collaboratively ask her, “How do you feel about what I am will say to your mum?”. Her reply would be something like, “Good”, nodding her head affirmatively while she did her chosen activity.

The conflict of Mary’s mum and grandma arguing over the top of her, along with other incidents regarding her father disclosed to me by Mary during our session together, made me wonder around the possible situation of the parenting parties not coping at times effectively with their parental role. I pondered that this could be due to the various current life stressors they were experiencing from the recent separation, along with practical and emotional adjustments being made to cope with these changes. It indicated to me that Mary needed further support at home and that with positive intervention, this could be achieved for the benefit of everyone. These issues would also cause me to take Mary’s case to supervision with both my counselling supervisor as well as my agency manager during our regular supervision sessions. I also discussed the relevant matters with work colleagues for their feedback. Doing these things helped guide me in the chosen course of action I responded with on each occasion.

Contracting –
A client contract was completed at the first appointment which was jointly held with both Mary, and her mother being a familiar person, who could introduce me. I encouraged Mary to co-sign the contract as a way of her active involvement in the process . I also supported her inclusion in goal setting, where Mary said she wanted to be, “Happy” and not, “Be upset” anymore with her dad. Her mother indicated she also wanted her daughter to, “Be happy’, as Mary had become more, “Clingy” at home, wanting her to sleep willingly in her own bed again. I explained my role was to listen to Mary, help her to attain her goals to support her to be happier as she desired, and that I was a ‘safe’ person to talk to about anything she wanted to.

I explained confidentiality in simple terms letting her know that if I were worried about her safety, I would need to talk to her mum about it , so I could help her be safe and to feel ‘not scared’ anymore. I also explained that if I needed to talk to her mum about the things she said to me, I would always tell her that need at the time, so she can ask me any questions she has, to understand why and what would be said.

The sessions were provided at no cost according to our organisational policy. I set an initial minimum of six recommended sessions, explaining that Mary may require more sessions that would be determined with them both at that time, should she still have a need for my continued service . I further explained that the additional sessions can be because it can typically take a longer time for children to build rapport and trust to share information in a counselling relationship openly. That if there were ongoing or new issues being raised then this can be another reason for continuing past our customarily recommended number of sessions. I also advised that I would regularly undertake both individual client progress and session assessments to monitor Mary’s progress, along with the effectiveness of my counselling approach for her.

Additionally, I explained to the mother the possible future need for referral to other services and/or notification to Child Youth & Family Services re any care or protection concerns, and how I would discuss this with her first should this need arise, which she indicated she understood and consented to.

I also explained my obligations under both our organisational policy but also the Code of Ethics from the New Zealand counselling organisation that we worked under, the requirement for me to undertake supervision, and that Mary’s case would be included in my discussions, which Mary’s mother further consented to.

With both their now fully informed consents and signed consent to share information form with outside parties as prior agreed, I met and spoke with Mary’s teacher Mrs X, to explain I would be collecting Mary from class for counselling sessions each week. The teacher was then able to advise the best day and time for this to happen , to be least disruptive to Mary’s education. Mrs X informed me she had noticed some concerning disruptive behaviours starting to occur over the last few months with Mary in class, where she would not engage fully in class at times and get, “Angry” with her classmates on occasion. She noticed this new behaviour particularly on the days following weekend visits with her father and that Mary was starting to come to school after these visits not dressed and groomed as usual, e.g. her hair not done and her uniform dirty. She reported in connection with her father’s visits, Mary would often be tired, falling asleep in class.

Intervention –
The beginning
Initially, during our sessions, Mary would draw or do other creative activities while she talked sometimes randomly about her current life events since our last session, or responded to simple open-ended questions asked of her, e.g. “What did you do on the weekend?” alter natively, “What have you been doing at school this week?”.
I chose to base my primary therapeutic approach from a Person Centred Therapy (PCT) perspective which incorporates the core skills of unconditional positive regard for the client, being congruent myself – which intrinsically encourages congruence within the client and to be empathic in my work with Mary. I enjoy working from the PCT methodology because it considers, “Clients as their own best authorities” (Mulhauser, 2016) in finding their path through self-determination. This idealogy is complementary to my own long-held personal view that people have the knowledge they require within them, but sometimes become so ‘bogged down’ with their problem or issue that they often only need gentle, supportive approaches to access that inner wisdom . I further believe that when people are empowered to activate this skill, their personal motivation is increased to make the necessary changes required to ‘fix’ the issue concerning them. The ability to then be able to tap into this skill allows people a more independent, autonomous life.

I routinely incorporated counselling micro-skills in my interactions with Mary such as ‘Attending’ where I would match Mary’s body language, lean forward and make regular eye contact to show my interest and acknowledgement that I am listening to her. I also utilised the micro skill of ‘Questioning’ during our sessions at times to further my understanding of her story such as, “When you say your dad says ‘bad words’…What words do you hear him say that are ‘bad’?”. She would respond with the exact words he said and why they are bad, such as, “Swear words are bad…I’m not allowed to say them”. By utilising these specific skills, the counsellor can productively enhance their communication with clients thereby assisting in a PCT approach. “These skills enable a counsellor to effectively build a working alliance and engage clients in discussion that is both helpful and meaningful.” (AIPC, 2009)

I also used the skill of questions to help her to think about her problems differently and then narratively create solutions for herself, e.g. “How about you draw a new picture where you don’t have to worry about all those scary things from your first picture. What will you draw in your new picture so you can feel safe and happy?” By using the Narrative Therapy (NT) concepts of,
The primary focus of a narrative approach is people’s expressions of their experiences of life. These are expressions of people’s experiences of a world that is lived through, and all expressions of lived experience engage people in interpretive acts. It is through these interpretive acts that people give meaning to their experiences of the world. These interpretive acts render people’s experiences of life sensible to themselves and to others. Meaning does not pre-exist the interpretation of experience. (White)
Also, “Options for the telling and re-telling of, for the performance and re-performance of, the preferred stories of people’s lives.” (White) Thus, through the more positive experience of the enhanced second story, the person is actively engaged in problem solving for themselves. Mary would then start drawing this new picture explaining it to me with the new elements, and why she thinks she would feel different, thereby interpreting her own experiences with newly gained meaning.

During one session she described a situation where she felt scared at night when she was at home in bed in her room alone, while her grandma looked after her during times when her mother was out at dance classes. In the picture Mary first drew, it showed where she was in her bedroom, a dark room, thinking about scary things like spiders, bugs and monsters and feeling alone, explaining that she would be thinking about when her mum would be returning home, so she could feel happy and safe again. Upon her mother’s return, she would consequently get into the bed with her mother to achieve this feeling. This was co-reported by her mother to be frequently happening. Not sleeping in her own bed was a new behaviour since the parental relationship separation, and the reported worrisome issues regarding Mary’s father’s conduct while she was with him on her scheduled weekend visits .

In Mary’s second picture, she drew new items such as a light for her room so that she could turn it on when she felt scared in the dark, her favourite teddy bear to cuddle, as well as a pet mouse to keep her company and feeling safe so that she wouldn’t feel alone. We then discussed these new elements being practically added to her night routine so she could feel safe and what would be required to make this happen.

Mary’s older brother consequently gave her his torch so she could use this to turn on when she needed, as he wanted to help his little sister when she explained her pictures to the family when she got home. Her mum brought her a pet guinea pig (she had wanted a pet for some time) which she kept in her room on the nights her mum was away from the house and would be removed again once her mum returned home. Mary started taking her favourite teddy bear into bed with her as well to cuddle on those evenings when she felt afraid. Within a week Mary was sleeping alone in her bed all night by herself again. She reported to me in a later session, that she was , “Happy now” with the new arrangements put into place and no longer getting up to go to the window to watch for her mum coming home.

Helping Mary and her family to support Mary through this experience of separation anxiety from her mum, helped both Mary and her family to work together to support each other, and that through collective problem-solving – problems can be resolved.
By using NT to enable Mary to be able to tell, and retell her story, she was then able to express it through Art Therapy which,
Children often lack the language skills to speak in detail about the issues they are having or the emotions they are feeling. Art therapy gives them a way to express and explore their inner selves and provides an outlet for externalising complex feelings. (Brown)
It also assists in children being able to engage in a therapeutic process and stay involved through creative experience and expression.
Mary proved she was able to come up with her own solutions by further assisting her with the subsequent use of Solutions Focused Brief Therapy (SBFT). This was done by following some fundamental concepts of SBFT such as, “Clients are the experts in therapy and must develop their own goals. Clients already have the resources and strengths to solve their problems.” (Ackerman, 2017) I also incorporated the further concepts,
Notice and reinforce evidence of the client’s positive qualities, strengths, resources, and general competence to solve their own problems. Work with what people can do rather than focusing on what they can’t do. Pinpoint the behaviors a client is already engaging in that are helpful and effective, and find new ways to facilitate problem solving through these behaviors. Focus on the details of the solution instead of the problem. (Ackerman, What is Solution-Focused Therapy: 3 Essential Techniques, 2017)

A little further into our sessions
During another early session as I have previously mentioned, Mary told me about an incident with her mother and grandmother fighting over the top of her in which she was physically hurt during this incident. I explained to her that it was important for me to be able to talk to her mother and grandmother about what happened to support them, so it didn’t happen again for her. She agreed to this, and I phoned the mother and arranged a separate meeting in which the grandmother and the mother would both attend at the earliest opportunity.

During that meeting, as per our initial meeting together, I again explained my ethical obligations under the New Zealand Association of Counsellors Code of Ethics regarding, “Counsellors shall take all reasonable steps to protect clients from harm. Counsellors shall, in their professional practice, take responsible action to challenge violence and abuse of power.” (NZAC, 2016)

They both admitted to the facts as described by Mary however during the meeting the grandmother started to become visually upset and responded verbally defensively to what had happened. I was then able to explain to them that I wanted to support them as dual guardians of Mary to have the necessary skills and support to care for Mary in a non-violent way. They both spoke of struggling with the recent changes of the mother’s separation which had caused them to commence living with the grandmother as the mother had left her family home for safety, and that the changes in Mary’s behaviour occurred since this change. During the discussion, I suggested that a free local parenting short course with the PPP program may be of some benefit in dealing with the problematic behavioural issues they were now seeing in Mary, and causing turmoil for them. They both agreed to this idea and completed the program confirming significant advantage gained from the new skills learned in the program , in not only assisting with parenting Mary, but also her older brother.

Mary later told me in her sessions that she was happy her two main carers were doing the course and things are, “Better” at home with no further incidents. She reported that her mum had started to spend some one on one time with her, which she greatly enjoyed the things they would do during this time, and how it made her feel, “special”. She informed me that her brother had also started receiving the individual attention too with his one on one time with their mother. Mary reported getting along with him better as well since the changes at home.

The middle
Mary further disclosed as the sessions progressed, that her father had been using inappropriate language by swearing when he got angry, and at times yelling while he did so. She also spoke of other concerning behaviours such as him helping her shower which she didn’t like , explaining that she can “Do it for myself”, along with sleeping in her dad’s bed because he told her too . She reported that he, “Sleeps in his underpants” which she thought was, “Gross”. This would often occur after being allowed to stay up many hours after her normal bedtime. She complained she did not sleep well with him because he held onto her, “Too tight” and she consequently felt tired the next day.

I again explained to Mary that I needed to talk with her mum about these issues to help solve them, given that these issues were for ‘adults’ to fix alone, and she did not need to do anything further. I thanked her for trusting me to tell me these worries for her. I then spoke with the mother about the concerns following which she engaged her lawyer to assist with the issue, by relaying the concerns to her ex-partner as she now had a protection order in place and had no contact directly with her ex-partner. The proposed actions from the lawyer to the father were;
1. Allowing Mary to shower herself.
2. Ensuring Mary has a consistent bedtime.
3. To ensure Mary sleeps in her own designated bed.
4. Stop using offensive language around Mary.

I explained to the mother that I had sought consultation from my manager over the issue and was instructed to report the concerns to Child Youth and Family (CYF) since I had no relationship with the father to address the concerns directly. She agreed with this plan and a care and protection concern notification was made to CYF further to our conversation. The social worker involved contacted me to clarify the information in the report, explaining she would interview Mary and the parents as soon as possible thereafter. During a later session together Mary told me about a lady who came to visit her at school to speak with her about her dad as a new happening of the week. I confirmed with her that she was brave for talking to the lady in which she merely concluded she was, “Ok ” with it quite matter of factly.

The end…
Beca use I was leaving the agency I worked for, I needed to bring an end to the counselling sessions with Mary sooner than I thought was therapeutically beneficial to her. I explained the situation to both Mary and her mother. I was then able to recommend further counselling support which was arranged with another provider for Mary. This was due to my concern regarding Mary’s report of continued unpleasant issues for her in our last session s together. Despite things being better at home for both Mary and her family, her continued visits with her father still showed ongoing unchanged behaviour from him regarding Mary’s previous disclosures. The mother again reported the ongoing issues to her lawyer to deal with, as current parenting order issues were also co-occurring. I informed my manager of these actions who then decided the agency nor myself did not need to take any further action, so I closed the agency file as CYF were already involved.

Outcome / Evaluation –
I undertook regular client evaluations as part of our agency practice. I commenced this in the beginning at our first session and then on every third session to determine Mary’s satisfaction rate with her life using the Child Outcome Rating Scale by Barry L. Duncan, Scott D. Miller, ; Jacqueline A. Sparks, and then included the Child Session Rating Scale by Barry L. Duncan, Scott D. Miller, Jacqueline A. Sparks from the third session onwards. Both of these assessments are specially designed for children aged six to twelve years old. As Mary was a child, I staggered these evaluations on different sessions so as not to be too onerous for her to do them, and being careful not to take away from our therapeutic time together from her perspective.

These self-assessments helped us both to visually see how she was progressing from the beginning, as improvement was increasingly evident in her scoring. It also gave her an opportunity to tell me in a safe way, what she liked and wanted to see changed in our sessions together. One such change was she decided she wanted to increase the variation of creative activities in her counselling sessions providing feedback she was now becoming, “Bored” with drawing, colouring in and various other activities such as dot to dots she had been doing. She determined she wanted to include more crosswords and some word search puzzles into our sessions. Receiving this feedback was helpful for me to learn to be open to client feedback as a tool for positively enhancing my counselling skills, but also to learn from and understand the experience of the participant to ensure they are engaged in a way that is meaningful and helpful to them.

Furthermore, I learnt significantly from the experience of the meeting I had had with Mary’s mother and grandmother whereby I explained that Mary had made a disclosure of harm incurred to her, and the content of that harm as described by Mary. Notably , that I had not crucially prefaced the conversation with a clear explanation of my intended sup port to assist the whanau. That it was not a punitive meeting in any way, and having dealt with this, I would have allayed the underlying fear and anxiety they experienced.

In my anxiety regarding the meeting, I made a cultural oversight in that I forgot to offer a karakia at the beginning and end of the meeting. Doing this would have helped me to also acknowledge the whanau’s Maori culture appropriately by recognising not only the importance of karakia should they have wished to perform it, but also the significant individual roles in the whanau regarding whom the karakia is performed by. This being, the grandmother as tipuna and kuia, and including the mother as whaea, and the significant roles they each play.

Another learning was that I had neglected to incorporate the importance of a specific cultural issue of intergenerational colonisation experiences into my meeting with my Maori whanau as per the NZAC Code of Ethics, explicitly regarding, “Act with care and respect for individual and cultural differences and the diversity of human experience. Actively support the principles embodied in the Treaty of Waitangi.” (NZAC, 2016) I failed to recognise in the instant that I was a pakeha Counsellor, approaching a specific sensitive issue, with Maori clients. I assumed that my existing ‘good’ relationship with them and the fact that I had previously encouraged open communication being that our relationship was a ‘safe space’ to voice concerns, was enough to commence the discussions. I did not think to consider any further issues when planning my meeting with them apart from the care and protection concern I had for Mary. I did not explain my intent for supporting them through the issue at the outset of the meeting, choosing to go straight into the meeting content after initial mihi between us. My oversight caused them to feel fearful (which I learned from my resultant conversation with them) that punitive action would be taken against them regarding the incident involved fearing Mary would be removed from the ir care. This also caused the grandmother to respond defensively initially , until my discussion with them both revealed these true joint underlying feelings, which my assurance of support for them was then made, albeit late with the emotional harm already been done.

I failed to recognise not only the power imbalance but the cultural significance to the situation that I had in this scenario, and its effect to negatively impact positive engagement. Due to the consequent learning I experienced from my error through my shame, this is something I have not made the same mistake on again. I now always ensure I consider cultural issues along with any potential power imbalances, always prefacing my intended support from the outset of the meeting for the person/s involved. I openly encourage them to freely voice any fears, concerns or disagreement they have immediately throughout any conversation, as a safe space to talk honestly and openly, so that collegially we can form any necessary plans forward as required. I continue to work reflectively to ensure I learn continuously from my practice experiences both ‘good’ and ‘bad’, taking any ‘wonderings’, concerns or reflections I have to cultural, counselling and/or organisational supervision as well as discussing it with experienced colleagues.
As a result of this error, I immediately sincerely and honestly apologised to them for my mistake in not acknowledging these issues from the outset, assuring them it would not happen again for them or anyone else, as they had helped me to learn a valuable lesson. I also thanked them for their courage in honesty with me. They, fortunately, accepted my apology, and our relationship remained encouragingly intact moving forward. This became finally evident by their verbally expressed appreciation of the work I was undertaking with their whanau along the journey, as well as at the cessation of our time together, the whanau came to my workplace and together they graciously presented me with a gift. The gift was a card which they all signed, and a Peace Lily plant with the symbolic meaning of wishing me ‘peace and prosperity’ in my new career adventures as a way of thanking me for my assistance with them, which I felt truly grateful for.
Discussion –
As this case was amongst many for me as a new counselling practitioner, I discussed this case in both counselling and agency supervision, including with colleagues on several occasions. It was a valuable professional learning experience, being a diverse case not only involving the client Mary, but her whanau members at all stages. I had several foundational learning curves along the way which have positively impacted my ongoing practice to date, through developing my weaknesses as not only a newly practising counsellor at the time but also as a new resident of New Zealand .

I needed to continually negotiate with all parties around confidentiality and consenting to share information amongst the parties, but also to outside organisations for the most effective outcomes. I also had to consider ethical and legal issues around dealing with and reporting of care and protection concerns for Mary on several occasions. I utilised multiple modalities, evolving into an eclectic counselling approach to support and work with Mary throughout our sessions. I needed to consider many cultural issues and develop cultural competence which is importantly based around Te Tiriti of Waitangi, through compliance with the NZAC Code of Ethics. I struggled through the mistake I made regarding my initially tricky meeting with Mary’s mother and grandmother, ensuring I learnt from this valuable experience to evolve my practice positively moving forward.

Lastly, I strengthened the importance of my working in cognisance with my core values of honesty, equality, respect, humility, openness and kindness. That by doing so, I deepen my therapeutic connection with my clients for the benefit of all parties involved.

Reference List –
Ackerman, C. (2017, September 28). What is Solution-Focused Therapy: 3 Essential Techniques. Retrieved from Positive Psychology Program: https://positivepsychologyprogram.com/solution-focused-therapy/

Ackerman, C. (2017, September 28). What is Solution-Focused Therapy: 3 Essential Techniques. Retrieved from Positive Psychology Program: https://positivepsychologyprogram.com/solution-focused-therapy/

AIPC, A. I. (2009, October 16). Five Counselling Microskills. Retrieved from AIPC Article Library: http://www.aipc.net.au/articles/five-counselling-microskills/

Brown, S. (n.d.). The Benefits of Art Therapy for Mental Health. Retrieved from Be Brain Fit: https://bebrainfit.com/benefits-art-therapy/

Mulhauser, D. G. (2016, February 26). An Introduction to Person-Centred Counselling. Retrieved from Counselling Resource: https://counsellingresource.com/therapy/types/person-centred/

NZAC. (2016). Code of Ethics: A Framework for Ethical Practice. Retrieved from New Zealand Association for Counsellors: http://www.nzac.org.nz/code_of_ethics.cfm

White, M. (n.d.). Narrative Therapy. Retrieved from Massey University New Zealand: https://www.massey.ac.nz/~alock/virtual/white.htm

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