Assessment of Clinical Practice

Adolescent Family Counseling for Substance Use and Depression
I. Setting the Scene
1. Destination Hope provides mental health services to a broad client base, with areas of specialization including family care and substance abuse intervention. It is a multifaceted and multimodal treatment center that provides individual, family, and group therapy options. In addition to acute and residential care options, Destination Hope also offers structured outpatient and long term options for individuals and families to help prevent relapses and promote quality of life.
2. Jim is a fourteen year-old Caucasian male, whose sister died in a car accident four months prior. Losing a sister is challenging enough for any individual; for one going through puberty at the same time, the effects of emotional devastation and loss can be confusing and even traumatic. Therefore, Jim’s behaviors, his shift in social scene, and his differential identity during this time do need to be viewed in context. Perspective can help Jim’s parents understand that changing one’s peer group and experimenting with different identities is a typical part of the transition from childhood to adulthood.
However, Jim’s father is a recovering alcoholic. When beer bottles and evidence of substance use surfaced in Jim’s life, his parents were understandably concerned. Likewise, Jim’s personality changes—such as being more withdrawn and not participating in class—are possible warning signs of ineffective coping. Whether or not Jim’s behaviors are due to suppressed emotions connected with the trauma of losing his sister, or whether those behaviors would have manifested regardless, is irrelevant in this case. In fact, Jim’s father has used silence and suppression of emotion as the means by which he deals with stress and trauma. Jim’s behaviors could be a result of modeling his father. What matters most is helping Jim and his parents cultivate new coping strategies that lead to improved daily functioning and psycho-social wellbeing.
3. Jim’s parents brought him to counseling after they found empty beer bottles and empty compressed air cans in their son’s room. Mutuality between the teenage client, Jim, and the counselor was established in spite of the fact that Jim denies that his behaviors are problematic. Likewise, Jim’s mother is less concerned than his father about the substance use and more generally worried that her son may not have effectively dealt with the loss of his sister four years ago.
II. Client-Worker Transactions
In accordance with American Psychological Association (2007) guidelines for record keeping in clinical practice, detailed accounts of client-counselor transactions were recorded. Level of detail promotes accuracy, and also helps other case workers maintain continuity of care (American Psychological Association, 2007). The following transactions took place during the first and second sessions working with the client and his family, and represent the application of core skills competencies throughout the interactions with Jim and his parents at Destination Hope.
Jim and his parents (mother and father) arrived for the session on time. Jim sat between his parents. Jim’s mother initiated the discussion by stating first that she and her husband loved their son, and that they had been worried about him after finding empty beer bottles and compressed air cans in his bedroom. Jim’s father remained silent, and so did Jim. Both Jim and his father looked down or around the room, appearing disengaged. However, when they were asked questions directly, they responded cogently and were obviously paying attention and following the conversations.
Worker asked Jim directly, “What would you like to say in response to what your mother just told us?” This question represents the use of open-ended questions. To this, Jim rolled his eyes, his face assuming a demeanor of annoyance and impatience. He said, “I was just experimenting, it’s no big deal. I’m not that into it, I just wanted to see what it was like, and I did.”
Jim’s mother then said, “And did you like it?” Jim responded, “No. Maybe. I don’t know. I really don’t see the big deal.”
Jim’s father spoke up for the first time to say, “It is a big deal, and you know it. That’s why we’re here.” Jim remained silent and folded his arms across his chest.
Worker then said to Jim, “Jim, why do you think your parents brought you here today?” Again, this represents an open-ended question. Jim replied, “I guess they’re worried about me.” Worker asks open-ended question to both parents, “Would you both agree with what Jim just said? What are your reasons for coming here today, as a family? What other issues besides your concern for Jim’s behavior would you like to discuss? Perhaps we can all talk about our goals in therapy. Let’s start with you, Jo-Anne (referring to Jim’s mother).” Shulman (2011) underscores the importance of these types of establishing questions during intake and rapport-building sessions with clients.
Jo-Anne reiterated her love and concern for her son, who is fourteen and “vulnerable,” to use her words. “He has been hanging around a different group of friends, which is fine, but he seems a lot less interested in school and other activities lately and we want to make sure that he remains healthy and happy. He still has good grades, but his teachers have been informing us about early warning signs in class. When he was suspended for the first time due to skipping school, that was when we really knew something was up. Everyone gets in trouble now and again, but if we don’t pay attention to it now, it could become worse.”
To this, the worker used mirroring and other communication techniques for establishing empathy with the client. The worker said, “I see that you have been allowing your son to grow and mature into a young man, but that you want his increased freedom to be tempered by a sense of awareness, intelligence, and personal responsibility.” Reading myself, I believe I may have read too much into what Jo-Anne was saying, but she did confirm what I had said. I think that my response was based on a small degree of transference with the client. If I had the chance to respond differently, I might have just said that I recognized her concern for her son, before turning to the father for his input. Gender may have played into my differential responses to the mother and the father, who was much more reticent during the intake session. New skills that were developed during this initial session included all of the beginning phase/first group dynamics Shulman (2011) outlines.
Modulation of expressions and communication styles is another key skill exhibited throughout the second session working with the client in family therapy. Zhang, Filbin, Morrison, et al. (2019) found that when working with diverse clients, “counselors do indeed change their conversational behavior to become more diverse across interactions, developing an individual voice that distinguishes them from other counselors,” (p. 1). The unique voice of the worker helps differentiate the cognitive-behavioral techniques employed specifically for this client, providing the individualized attention Destination Hope prides itself on. This way, differences in age, gender, socioeconomic background, religion, ethnicity, or linguistic heritage are acknowledged openly in an arena of trust. For example, the worker asked the father, “How did your father and mother deal with conflict, crisis, or the difficult feelings surrounding loss or death?” This open-ended question established rapport with the father, and also demonstrated the worker’s development of core skills such as reaching for feelings and putting feelings into words (Shulman, 2011). The goal of this session was also to delve deeper into the surrounding trauma of the sister’s death, and to ascertain to what degree Jim models his behavior to match that of his same-sex role model.
Reading the client(s) in this case involved observations of body language, but also frequently asking the client directly if my suspicions, assumptions, or impressions were correct. I believe I did a good job of avoiding unnecessary biases and assumptions by checking in with the clients regarding factors like gender roles and parenting styles. When the father derisively referred to Jim’s new social group as “Goth,” for example, I asked the father what “Goth” meant to him and why that subculture bothered him. The father responded that the “Goth” kids seemed antisocial. Jim quickly butted in, one of the first times he interrupted anyone or spoke before being spoken to. Defending his lifestyle, image, and his friends, Jim claimed that their friendships were formed around interests in human and that “my friends understand me, unlike some people.” When I asked, “What do you mean by that?” Jim said that his old friends only cared about material things or sports, and that he cared about “deeper” things. I then asked his parents how they could support Jim in cultivating new hobbies and interests in a productive way, such as by asking Jim whether he wanted to become more involved in some type of creative pursuit. Using empathy skills, I also said that it seemed Jim was in a phase of “wearing different hats,” trying on new identities to see what works for him, and that refraining from judgment might help promote harmonious home environments.
One transaction involved probing deeper into the father’s reaction to their daughter’s death, with the goal of demonstrating the downside to emotional self-suppression. Yet the worker refrained from overtly stating as much, keeping in mind cultural and personal biases regarding preferred methods of dealing with trauma and pain. Moreover, gender roles and norms likely factor into how the father dealt with the death of their daughter and how he reacts to his son’s behavior. Jim may believe that suppressing his pain is what his father wants or expects, and in future sessions it would be helpful to unpack the gender-related barriers to emotional self-mastery and emotional intelligence. If Jim were provided with the support structure necessary for authentic self-expression, perhaps through another type of group therapy, then he may come to modulate his emotions without relying on self-harming behaviors such as withdrawing socially or using alcohol and drugs.
The use of cognitive-behavioral therapy in this session was deliberate. Adolescents engaging in self-harm behavior, including substance use, respond well to various types of cognitive-behavioral interventions in clinical trials (Taylor, Oldershaw, Richards, et al., 2011). Likewise, Oud, de Winter, Vermeulen-Smit, et al. (2019) found CBT “effective for youth with a (subclinical) depression,” (p. 33). When caregivers were involved in the therapeutic process as in Jim’s case, the CBT proved especially effective (Oud, et al., 2019). Particular CBT interventions of note for working with clients like Jim include behavioral activation and challenging thoughts, classic CBT techniques. Hogue, Bobek, MacLean, et al. (2020) extend the range of CBT interventions for adolescents with externalizing behaviors to include the following: “functional analysis of behavior problems, (b) prosocial activity sampling, (c) cognitive monitoring and restructuring, (d) emotion regulation training, (e) problem-solving training, and (f) communication training,” (p. 1). The plan in future sessions working with Jim and his family will be to incorporate as many of these CBT interventions or techniques as possible, noting in formal records which methods Jim or his parents prefer and are more likely to employ as long-term solutions.
Further worker self-reflection demonstrates competencies in the construction of a supportive relationship between the counselor and clients. King (2016) claims the skills most important to working with adolescent clients include “through supportive relationships, positive expectancies, and mastery and learning experiences,” (p. 1). In fact, these supportive relationships can cross over into the structure and nature of the relationships between the family triad and its corresponding dyads. Language used in the session was deliberate and respectful, too, helping all three family members to engage in active listening and other mutually supportive styles of interpersonal communication during family engagement. The language counselors use in therapeutic sessions is of critical importance, setting the tone for therapy and also promoting empathy and understanding to mitigate differences in culture or worldview (Rodriguez, Walters, Houck, et al., 2017).
III. Description of Learning
Interpersonal stressors are inevitable in life; family therapy and CBT can reveal diverse coping strategies for managing stressors and perhaps even benefitting from them. Family-based therapy and CBT together comprise the most effective psychosocial interventions for adolescents at risk for substance abuse (Fadus, Squeglia, Valadez, et al., 2019). Working with the client in these sessions, and critically reflecting on the clinical practice environment and process, promoted the development of core counseling competencies.
I learned a lot about myself during these sessions, and also about the process and purpose of CBT. Godley & Passetti (2019) note that family-based, motivational, CBT-oriented approaches like the ones used here including the Adolescent Community Reinforcement Approach have the “strongest empirical verification” for preventing relapse and ensuring long-term positive clinical outcomes (p. 1). Evidence-based practice norms require mental health workers to employ the latest empirically validated techniques, from specific CBT methods to methods of self-assessment.
The sessions with Jim and his family brought to light the difficulties in maintaining the delicate balance between empathy and overreaching. For example, I may believe that I am “connecting” or “feeling” the client, but my sense of understanding may be based on false impressions or assumptions. It may be impossible to ever know for sure whether we are on the exact same page as a client. Their willingness to self-disclose, especially in a group setting, may be constrained by a number of factors. In the future, I would prefer to see Jim in an individual counseling session, as well as each of his parents in a one-on-one basis, in order to deepen the rapport.
Processes used in family-based CBT do need to be grounded in empirical knowledge about what actually yields tangible, measurable, long-term results. Monitoring Jim’s behavior, keeping track of his performance in school, remaining in touch with teachers, and encouraging his parents to be less anxious and more supportive may be the most important ways of preventing Jim from going down the road his father fears the most. For Jim, the use of CBT will help him develop emotional intelligence and counteract the poor emotional self-management skills his father has represented to date.
References
American Psychological Association (2007). Record keeping guidelines. American Psychologist 62(9): 993-1004.
Fadus, M.C., Squeglia, L.M., Valadez, E.A., et al. (2019). Adolescent substance use disorder treatment. Current Psychiatry Reports 21(96).
Godley, M.D., Passetti, L.L. (2019). Behavioral interventions for substance use and relapse prevention. Treating Adolescent Substance Use. https://doi.org/10.1007/978-3-030-01893-1_6
Hogue, A., Bobek, M., MacLean, A., et al. (2020). Core elements of CBT for adolescent conduct and substance use problems. Cognitive and Behavioral Practice(2020): https://doi.org/10.1016/j.cbpra.2019.12.002
King, G. (2016). The Role of the Therapist in Therapeutic Change: How Knowledge From Mental Health Can Inform Pediatric Rehabilitation. Physical & Occupational Therapy In Pediatrics, 37(2), 121–138. doi:10.1080/01942638.2016.1185508 
Oud, M., de Winter, L., Verimeulen-Smit, E., et al. (2019). Effectiveness of CBT for children and adolescents with depression: A systematic review and meta-regression analysis. European Psychiatry 57(2019): 33-45.
Rodriguez, M., Walters, S. T., Houck, J. M., Ortiz, J. A., & Taxman, F. S. (2017). The language of change among criminal justice clients: Counselor language, client language, and client substance use outcomes. Journal of Clinical Psychology, 74(4), 626–636. doi:10.1002/jclp.22534 
Shulman, L. (2011). Dynamics and skills of group counseling. Belmont, CA: Brooks/Cole.
Taylor, L.M., Oldershaw, A., Richards, C., et al. (2011). Development and pilot evaluation of a manualized cognitive-behavioural treatment package for adolescent self-harm. Behavioral and Cognitive Psychotherapy 39(5): 619-625.
Zhang, J., Filbin, R., Morrison, C., et al. (2019). Finding your voice. arXiv:1906.07194 [cs.CL]