A counselor like any other physician, or medical practitioner must help. That is their first and only objective.
The relationship between a counselor and their client must first and foremost be a beneficial and safe one. If at any point either party begins to feel as though the relationship is no longer helpful, or either party feels threatened in any way then the relationship must be terminated. Treatment should never be denied based on race, creed, religious belief, sexual orientation, or previous criminal history. The letter and spirit of the laws regarding confidentiality and the use of patient's records should also be adhered to. A client must be able to trust that the information disclosed in therapy sessions will not ever be leveraged against them unless they have specific knowledge of a criminal act which results in duly appointed authorities being awarded a subpoena for the records, or they express intent to harm themselves or others. These exceptions must be made clear at the onset of treatment, never expressed as a threat, rather as a part of a counselor's legal and ethical obligation to fully inform the client of their rights before any personal or private information is disclosed. A therapeutic relationship must be professional yet the nature of the profession indicates that the relationship will become highly intimate. It is very important in this context not to become personally involved with the client beyond the appropriate boundaries of a counselor client relationship. Romantic or even friendship with a client is extremely inappropriate as the power dynamic within the relationship is skewed heavily in favor of the counselor.
The counselor is the catalyst for change. It is a primary tenet of psychology more specifically psychotherapy, that a counselor will be unable to affect change unless the individual desires to change themselves. This is fundamentally true. However, it is apparent that Vera seeks change. She has sought therapy and assistance from her mother in the past and is now doing so again. If she is able to develop a relationship with a therapist whom she trusts and who is able to make her believe that she can cope effectively without the self-medication then she will succeed. If however, she does not find such a relationship, it is likely she will continue on the path she is currently on indefinitely. The relationship between counselor and client is infinitely important, it is this relationship which actually facilitates and directs the changes an individual needs in order to achieve their goals and discontinue maladaptive behaviors they are not able to cease on their own.
Personally I ascribe to a combination of psychodynamic psychotherapy and cognitive behavioral psychological approaches. While psychodynamics is essential in developing a healthy open and honest relationship with a client, it is the cognitive behavioral therapy which actively works towards identifying and eliminating maladaptive thought processes and behaviors. Neither of these approaches though are effective without a respect and understanding of the biological roots of these negative behaviors. A careful analysis of family and personal medical history as well as a full blood work up are crucial first steps in developing an effective therapeutic relationship.
One of the most effective aspects of psychodynamic therapy is that there is an open reciprocation of information. Where psychoanalysis requires counselors to remain relatively silent, a daunting proposition for an individual with self-esteem issues and depression, psychodynamics encourages active question and answer, interaction. Rather than a sense of being judged, the client feels like they're having a particularly uplifting conversation. The result is a feeling of empowerment and self-respect, reflected from the respect shown them by the counselor. While psychodynamics are important in empowering and understanding a client, this alone will not resolve maladaptive thought and behavior processes. For that a specific assessment of individual behaviors a deconstruction of those behaviors and replacement of them with positive strategies is necessary. Personally, I believe that these two techniques should never be used independently. Psychodynamic sessions are extremely effective in building rapport and cognitive behavioral therapy is extremely effective in affecting specific behavioral change.
Should Vera enter my office, my treatment approach would be multi-modal. Necessarily I would need to take over the management of her current medication regimen. Assuming though, that as evidenced by her symptoms the medication regimen in place is no longer effective I would likely taper her off her existing medications and start over. According to the client's wishes I would send her for a full blood panel not only checking for the presence of sexually transmitted diseases, but also ordering a full biochemical profile as well as a toxin screening. As part of our counselor client contract I would insist that the substance abuse stop. To facilitate this I would refer Vera to a residential rehabilitation clinic for a period of 1 week minimum and 1 month maximum during which we would maintain our normal weekly session. Though a controversial decision, the break from her current daily habits and her current and unhealthy environment would be therapeutically useful in the distinction between her previous life and her new life direction.
During this initial period of detoxification with the client's permission I would bring her biological parents, step father, and boyfriend in for a session. Individually first then I would have them all come in for a group session. During their independent sessions, I would assess their individual role in Vera's life and address the negative aspects of their relationship with my client. It is essential especially for a person in Vera's unique situation that while her body is detoxing, those people in her life are detoxed as well. Her boyfriend facilitates bad habits, her mother also facilitates perhaps out of guilt, her father was abusive and is not apparently with no reason trying to come back into her life. Without a concentrated and unified effort from the people closest to her Vera will likely lapse. As such it is essential that they are all a part of her therapy. If they love her, and want her to be better, then they will have to get on board with a strategy that will work.
Following her time in rehabilitation, I would give Vera approximately one week of complete reprieve from medication. Should her depressive symptoms persist, resulting in chronic impairment as she is currently experiencing I would most likely prescribe an MAO-I. While this is a relatively uncommon class of antidepressants, the side effects are largely void of anxiety and anxiety inducing symptoms. It also has the added bonus of depressing sexual appetite which may curb Vera's impulsive promiscuity. MAO-I's do not generally cause weight gain, Vera has a problem with self-esteem, sudden weight gain or bloating would likely also be counterintuitive to effective treatment. The drug itself also reinforces her sobriety as it can be used in the cessation of smoking addiction. The goal though would be to eventually wean Vera off medications entirely, resulting from effective therapeutic techniques which will help Vera learn to identify and manage her symptoms as well as their cause.
The first phase of therapeutic treatment would focus largely on motivational interview and psychodynamic psychotherapy. These therapeutic techniques are client centered and function primarily to get the client talking openly about what they are feeling, and thinking. The motivational interview also will help Vera determine what goals she desires and give her positive support and reinforcement helping to indoctrinate her with the belief that she can infact affect the changes necessary in her life to achieve those goals. Especially with a client expressing depression, with a history of suicidal ideation it is essential to shift their focus from a sense of helplessness and guilt to one of empowerment and positive motion. This is crucial during the first few weeks of treatment with MAO-I's as it takes up to four weeks for the full effects of the drug to be felt. Giving Vera a journal, I would also give her a series of empowering phrases to say every morning and every evening. She would also be instructed to say them when she felt overwhelmed or unable to cope. I would also help her develop a schedule for every day, despite her unemployment giving her something to do, a specific reason to get out of bed would be useful in breaking the depressive cycle. Finally I would give her an increasingly complex series of micro goals, showing her tangibly that she can succeed. These micro goals would eventually give way to larger longer term goals.
Once Vera began to show improvement in her self-concept, and we had reached a stage where she was reasonably comfortable speaking openly and candidly with me I would begin cognitive behavioral therapy. The reason I would leave this mode of therapy until later in her treatment is that specifically addressing maladaptive behaviors in a client who is already in depressive crisis may ultimately be more harmful than helpful. Before she can change, she needs to believe that it is a possibility. Through cognitive…