Crisis Intervention Practice Session When

Crisis Intervention Practice Session

"When you can accurately hear and understand the core emotional feelings inside the client and accurately and caringly communicate that understanding to the client, you are demonstrating effective listening…" (Bracewell, et al., 2010)

Overview of the Session

The client in this case is unable to stop consuming alcohol and in fact she smelled of alcohol prior to arriving at the session. The positive part of this session, seen from the outset, is that she has decided to seek help for her addiction. A woman in her fifties may be going through or approaching menopause, and she is certainly going through changes as she moves into midlife. But given that she has a problem with alcohol, any other issues pertaining to her life and in effect dragging her down from where she once was are exacerbated by the drinking obsession. Some very creative and proven strategies are needed in this therapy; the basis for those strategies will be cognitive behavioral therapy.

Research on 50-Something Women and Substance Abuse

Prior to the arrival of the woman (Gina) in my office, I need to research the issues that surround a woman in her 50s who may become involved in abusing substances such as alcohol. Few if any of the specifics of the research will necessarily apply to Gina, but having a broad psychological and social background on women who may be approaching, or going through menopause -- who also have a drinking problem -- is certainly important to the counselor / therapist. There will be no attempt to fit Gina's issues into a neatly pre-arranged package of therapy based on research into women her age struggling with alcohol, self-esteem, and depression.

However, as author George E. Vaillant explains, while men get drunk and it tends to be "…a source of merriment" in film and popular literature, "…intoxication in women (who develop alcoholism for the same reason as men do) amuses no one" (Vaillant, 1995,123). And because women can "…drink less alcohol safely" than men, and because there are "…stronger social sanctions against heavy drinking in women" than men -- and indeed because alcoholism is more stigmatized in women" than men -- women are up against "…more barriers to obtaining treatment" (Vaillant 123).

Given these realities, it is the assertion of Vaillant (a professor of Psychiatry) that the diagnosis of women is missed; there is the strong likelihood that women will be treated for "…secondary depression and anxiety rather than primary alcoholism" (123). Vaillant asserts that alcohol abuse seems to be the "…cause of psychological problems in women, rather than psychological problems causing the alcohol abuse" (124).

Regarding issues that Gina may have vis-a-vis menopause, Dr. Nada L. Stotland, past president of the American Psychiatric Association, explains "…menopause means aging" and "aging is frightening…so we pretend we are just halfway through life" rather than facing that age is catching up to us (Stotland, 2005 1).

Author Nancy Beckham referenced 108 research studies and conducted her own meta-analysis of those research studies; Beckham came up with six bullet points relating to menopausal stigmas. Several of those points are presented here: a) "life stresses account for much…of the variation in emotional well-being" during menopause; b) if a person has "negative preconceptions about the physical and emotional aspects of menopause" that leads to even greater "distress"; c) viewing menopause as a "…deficiency disease" leads to additional emotional problems vis-a-vis middle age; d) blaming personal emotional problems on menopause is like "masking" rather than solving the problems; and e) ten psychological studies show that "natural menopause leads to few changes in psychological characteristics" -- only a "decline in introvertedness" and hot flashes are the obvious, universal changes (Beckham 12).

Beckham includes the thought that negative attitudes toward menopause or a "lack of social support, poor marital relations" and life events that are "stressful" contribute to feminine problems in midlife (12).

Cognitive Behavioral Therapy and Gina -- Counseling Skills Used in the Session

The basic skills that will be employed in the session with Gina will be through the use of Cognitive Behavioral Therapy (CBT). According to psychologist Warren Mansell, the fundamental principle of CBT is based on somehow building a collaborative relationship between the therapist and the client (Mansell, 2010, 51). That sounds rather obvious and quasi-pedestrian, but without full collaboration very little can be expected to be achieved in the session. Rather than have the client view the therapist as a "…paternalistic figure who administers esoteric techniques" like free association or hypnotism, the therapist in this instance will have some analogies ready to utilize in order to establish a mellow, relaxed setting for the work that must be done.

Metaphors are a key part of Mansell's approach to CBT. Is Gina the kind of person that will readily accept a therapist who says there is not one, but two experts in the room? Will she think this is a ploy to make me feel important? But indeed, the therapist is supposed to have expertise in his or her field, and the client (according to Mansell) is "…not only an expert on [her] life, but also in their particular type of problem and how it works in the context of [her] live" (51). Another worthy metaphor to be used with Gina is the "architect and surveyor" approach. In this case the therapist is the architect, seeking to build a house in a "…scenic meadow with beautiful meandering streams" -- but he can't build the house without the assistance of a surveyor (the client). The surveyor can position the house so there will never be a problem if the streams flood over and there will be no problems with the quality of the land upon which the foundation will be built -- hence the need for the surveyor (Mansell, 51).

Yet another metaphor that will be embraced in this session is that the therapist is a "private detective" like the television drama, "Columbo," featuring a detective (Peter Falk) who is simply gathering information for a story in a "…quiet, curious, unassuming and even naive" approach (Mansell, 51). Still another metaphor in Mansell's bag of tactics is to say that the therapist is just a coach, helping his players develop their own strengths; and the client is a member of the coach's team who needs to learn how to develop strengths to "…deal with their problems" (52).

Mansell also employs the concept of "…going to the post office" (clients don't want to be pushed in the back, told where to go, hence they resist this approach) and using the therapist as a business consultant (the therapist / consultant is not in charge, but just wants to make suggestions on a better way to do things) (53). Brushing one's teeth (with the opposite hand than one is used to employing) is yet another of Mansell's strategies.

I asked myself, what should be the approach if Gina shows signs of anxiety, more so than what a therapist would consider normal nervousness at the seriousness and the unknowns that she is embarking on? If she shows generalized anxiety disorder (GAD), then CBT would seem to be the logical approach. Psychologists Jayne Rygh and William Sanderson posit that "relaxation techniques" -- an important component of CBT -- can lead to "…market reductions in the symptoms of GAD as compared with nondirective treatments" (Rygh, et al., 2004, 8).

Moreover, Rygh inspected the results of 13 "controlled clinical trials" -- that included CBT, cognitive therapy, behavior therapy, placebo or nonspecific treatment, and psychodynamic treatment of GAD -- and they concluded that in those trials "…CBT produced the most intermediate and long-term improvement in both anxiety and depression…" (9).

Use of Counseling Skills in Therapy -- Examples Provided

Gina enters the office, she has been warmly greeted, she offered her hand in a handshake and she complimented the "nice arrangement" of fresh-cut flowers on the desk. A general conversation takes place about her reasons for this appointment; both client and therapist are seated in the comfy chairs (I never sit behind a desk and peer down at the client in a patriarchal setting). She is nervous and fusses with her car keys before finally stuffing them into her purse, which is huge and bulging.

Therapist: Gina, how are things at work for you -- and how long have you been there?

Gina: I have been working for this company for 7 years and I like the work. I am a data input person but I actually do a lot more than that. I actually have helped the company set digital policies. But I've been temporarily laid off for now

Therapist: What happened?

Gina: I had a couple drinks at lunch one day and my boss asked me to stop doing that; but the next week I had a beer or two during lunch at a regional conference and he suspended my pay and I was asked to deal with my problem and come back in eight weeks.

Therapist: So are you ready to make some changes? Is that why you are here?

Gina: What do you mean, 'changes'? What would your role be in helping me?

Therapist: Thank you for asking. Let's just talk here at the beginning about doing things differently. How about this -- are you right-handed?

Gina: No, I'm left-handed, why?

Therapist: What if I asked you to start brushing your teeth with your right hand. Tonight, after your dinner, use your right hand.

Gina: Okay but that will seem weird and I might not be very good.

Therapist: Once you do it for a while, how would that seem to you? For example, your next appointment is in a week, that will give you 7 days to practice. How would that work for you?

Gina: I believe it would begin to seem fairly routine if I did it long enough.

Therapist: And seeing how this change could be possible could lead to other changes in your life. Are you ready here today to open the door to changes?

Gina: And what is your part in this? How do you work with me, a heavy drinker who admits to her problem but can't give up my drinks?

Therapist: Remember Gina, there are two experts in this room. I am trained and I have expertise in terms of helping people with their problems. And you are an expert on your life and you have expertise on exactly why you drink too much and why you came to me for help in cutting back. Right?