Charlotte is 11. She has been brought along to counselling by her mother, Fran. According to Fran, Charlotte has always been a “quiet and shy” girl. Fran remarks that she is not surprised by this as she too was a reserved and anxious child. In recent weeks however, Fran has noticed that Charlotte has become increasingly withdrawn. Charlotte becomes particularly upset before school and cries that she does not want to go. This is a new behaviour for Charlotte, who previously enjoyed school and excelled in class.

Fran is aware that Charlotte has recently become a part of program at school called, “Out of Our Shells”. This series of classes is designed to build children’s self-confidence. This program encourages participants to engage in activities that they would ordinarily shy away from, such as public speaking, approaching new people and standing up for one’s self.

As well-intended as the program may be, Fran is worried that it has pushed Charlotte well beyond her comfort zone and is triggering anxiety.

In counselling you discuss the program with Charlotte and discover Fran’s assumption is correct. Charlotte is so worried about the activities she is expected to do as a part of “Out of Our Shells” that she has become anxious about attending school all together.

Fran is eager for Charlotte to work on her self-confidence and assertiveness. Charlotte too indicates she would like help in those areas, but she begs to be excused from the “Out of Our Shells” program.

Charlotte’s father (Bill) is, however, adamant that Charlotte stay in the program. He feels it will be the quickest, most effective way to build her self-confidence. Charlotte’s teacher also highly recommends Charlotte continue with the program. Both Bill and Charlotte’s teacher are of the opinion that in a short amount of time, Charlotte will feel much more comfortable with the activities and enjoy the sense of accomplishment the program will give.

As Charlotte’s counsellor, how would you proceed?
Share your thoughts!

Enter your comments below or email them to blog@aipc.net.au and we’ll review it for publication at our quarterly newsletter “The Professional Counsellor”. Please include your full name, qualifications and contact details.

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Infidelity is increasingly becoming one of the most common relationship challenges in romantic relationships.  The acts of infidelity or cheating can have devastating consequences on those involved. Having been cheated on can result in anguish, depression, fury and humiliation (Brand, Markey, Mills & Hodges, 2007).

It has been suggested that infidelity is one of the leading causes of divorce and romantic relationship breakdown (Brand, Markey, Mills & Hodges, 2007). Click here to read more about infidelity…

With infidelity come consequences. Many people are impacted. If we were to step outside and look in for a moment, we may be able to see just how many people are affected. Firstly there is the betrayer. He/she has learnt to be an actor in order to not be suspected.

After being found out, feelings of shame, guilt, despair and confusion are evident. In most cases, the betrayer is forced into making a quick decision between two relationships. With that choice come huge impacts for the betrayer, including many of the losses described by the person betrayed. Click here to read more about the consequences of infidelity…

One of three events occur after the discovery of an affair. For some, nothing changes in the relationship and the affair is either ignored, denied, repeated, or continued. The affair can unfortunately also end a relationship depending on the intensity and length of the affair and the values of the parties involved.

For others, the occurrence of an affair can signal a reassessment of the existing relationship and provides an opportunity for change, growth and a more improved relationship. Click here to take a closer look at these options…

Finally, how can counsellors assist clients move forward after adultery? It all starts with re-building trust and re-establishing an effective communication channel. Click here to read more about Lin and Craig’s case study…

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Jocelyn works as a Human Resources Manager for a large international organisation. She is becoming more and more stressed at work as the company is constantly changing and evolving. It is a requirement of her job that she keeps up with this change by implementing new strategies as well as ensuring focus is kept on her main role of headhunting new employees.

She finds that she is working twelve-hour days, six days a week and doesn’t have time for her friends and family. She has started yelling at staff members when they ask her questions and when making small mistakes in their work. Concerned about her stress levels, Jocelyn decided to attend a counselling session.

Below is an extract from Jocelyn’s first session with her counsellor:

Transcript from counselling session

Counsellor: So Jocelyn, let’s spend a few minutes talking about the connection between your thoughts and your emotions. Can you think of some times this week when you were frustrated with work?

Jocelyn: Yes, definitely. It was on Friday and I had just implemented a new policy for staff members. I had imagined that I would get a lot of phone calls about it because I always do but I ended up snapping at people over the phone.

Counsellor: And how were you feeling at that time?

Jocelyn: I felt quite stressed and also annoyed at other staff members because they didn’t understand the policy.

Counsellor: And what was going through your mind?

Jocelyn: I guess I was thinking that no-one appreciates what I do.

Counsellor: Okay. You just identified what we call an automatic thought. Everyone has them. They are thoughts that immediately pop to mind without any effort on your part. Most of the time the thought occurs so quickly you don’t notice it but it has an impact on your emotions. It’s usually the emotion that you notice, rather than the thought. Often these automatic thoughts are distorted in some way but we usually don’t stop to question the validity of the thought. But today, that’s what we are going to do…

The counsellor proceeds to work through the cognitive behaviour process with Jocelyn as follow:

Step 1 – Identify the automatic thought

Together, the counsellor and Jocelyn identified Jocelyn’s automatic thought as: “No-one appreciates what I do”.

Step 2 – Question the validity of the automatic thought

To question the validity of Jocelyn’s automatic thought, the counsellor engages in the following dialogue:

Counsellor: Tell me Jocelyn, what is the effect of believing that ‘no-one appreciates you?’
 
Jocelyn: Well, it infuriates me! I feel so undervalued and it puts me in such a foul mood.

Counsellor: Okay, now I’d just like you to think for a moment what could be the effect if you changed that way of thinking
 
Jocelyn: You mean, if I didn’t think that ‘no-one appreciates me’?
 
Counsellor: Yes.
 
Jocelyn: I guess I’d be a lot happier in my job. Ha, ha, I’d probably be nicer to be around. I’d be less snappy, more patient.

Step 3 – Challenge core beliefs

To challenge Jocelyn’s core belief, the counsellor engages in the following dialogue:

Counsellor: Jocelyn, I’d like you to read through this list of common false beliefs and tell me if you relate to any of them (hands Jocelyn the list of common false beliefs).
 
Jocelyn: (Reads list)Ah, yes,I can see how I relate to number four, ‘that it’s necessary to be competent and successful in all those things which are attempted’.That’s so true for me.

Counsellor: The reason these are called “false beliefs” is because they are extreme ways of perceiving the world. They are black or white and ignore the shades of grey in between. 

Applications of CBT

Cognitive approaches have been applied as means of treatment across a variety of presenting concerns and psychological conditions. Cognitive approaches emphasise the role of thought in the development and maintenance of unhelpful or distressing patterns of emotion or behaviour.

Beck originally applied his cognitive approach to the treatment of depression. Cognitive therapy has also been successfully used to treat such conditions as anxiety disorders, obsessive disorders, substance abuse, post-traumatic stress, eating disorders, dissociative identity disorder, chronic pain and many other clinical conditions. In addition, it has been widely utilised to assist clients in enhancing their coping skills and moderating extremes in unhelpful thinking.

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Marcia, 29 years of age, came to you six weeks ago with issues of poor self-esteem and lack of self worth. She has been married for 8 years to Michael, however in session she speaks little about him and when the conversation turn towards him she quickly tries to change the subject or issue. Although you have noted this shift you have not challenged her regarding this relationship as you work on different areas and issues leading up to the relationship.

At the appointed time today Marcia shows up with an unannounced Michael for her session. He said he was there because Marcia was changing and he wanted to play a role in the process, while getting a notion about what was in Marcia’s mind at the moment.

Throughout the session you watch Michael dominate and bully Marcia into answers that she, you feel, would not normally give. At one point Michael tries to stand over you when you challenge this behaviour. Throughout the session you feel uncomfortable and have feelings of melancholy for your client.

At the end of a very strained session Michael declares that he thinks it would be better if he came to all Marcia’s sessions so he can see what going on and what you’re filling her head with. After they had gone and you have reflected on the session you discover how his behaviours and her passivity have triggered feelings of unresolved helplessness in you – similar to those that you felt when your parents displayed these behaviours.

As her counsellor, how would you react to this situation?

(click on the comments link below to view responses)

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Category: Group Counselling
Author: Kathleen Casagrande

A Support Group had been advertised on the display board of the local Drug and Alcohol Treatment Centre in the City where the Counsellor had been seeing each of the members for private counselling prior to the start of the programme.

Ten clients enrolled in the group but by 7:15pm only 5 of the ten group members allocated for the 7pm time-slot, had arrived. Cancellations and rescheduling unfortunately are an issue with people who are challenged with substance misuse. The 5 members present, included:

1. Gemma, whose partner died from drowning in a pool next to her at a party where there were many drugs being used of all types; mainly ecstasy, fantasy and speed.
2. Wesley, who has been out of prison for six months now. He has been addicted to morphine and heroin and has since taken up alcohol (because it’s legal).
3. Cobi, previously a paramedic who was diagnosed with A.D.H.D. and used amphetamine/methamphetamine (speed) because it used to get him through the horrors of his nights.
4. Effie (Frangelica), who has deep-seated self-esteem issues. She used to smoke cannabis, just to take her away from reality and ultimately aiming to de-stress her.
5. Jasmine, who became an alcoholic when her husband died in her arms from an operation that went terribly wrong.

The goal of the group was to share ideas and strategies associated with the maintenance and well-being of each group member. Each week a member would be expected to deliver a positive idea or event that happened to them during the previous week. 

Introduction

Group Facilitator will be abbreviated to GF.

GF: Good evening. I am the facilitator of this group where we will be predominantly working with the effects of addictions. We have all decided to create a support group for sharing our experiences, our strengths and our weaknesses so that we begin to understand that we are not alone in our situations. Because some of us have journeyed along a path that has been amazingly eventful, we all want to know that our stories are all confidential and must not be shared with others outside of this room.

If you choose to elaborate on a story that belongs to somebody else, please be aware that it is expected you do not use that person’s name. 

Please remember that my duty of care, as it exists for us in counselling, also applies here. So if I consider that you, or another person, are at risk of harm, I am obliged to uphold your safety and the safety of others. This may mean that I will need to disclose information to people outside of this group. Of course, where possible I will seek your support on this before acting. Is that understood?

GF: (Addressing the group as a whole) I would like to find out what everyone in the group thinks about the issues of addictions in their own lives. Let’s move around the circle now starting with you, Wesley.

Wesley: While I was in jail I was medicated most of the time because of my aggressiveness, I just wanted to fight everybody because I hated myself. I’ve been hated all my life from when I was a little kid, my mother would tell me all the time how much she hated me ’cause I looked like my Dad. 

So after five years of being given morphine for pain from many beatings and then heroin when I got out I didn’t want to start stealing again to keep feeding my habit so I slowly went off heroin with anti-depressants I got from the doctor, then I became addicted to Valium and used that too much with rum to wash them down. I know I was just swapping the witch for the bitch to cover my own self-loathing.  I realise this but I have all this anger inside me.

“Prescribing a drug also gives doctors the illusion that they have solved the problem while, in fact, all they have done is to postpone it, and they may have created a new problem in the process.” (Parkes, et al., 1996)

GF (after some further sharing from group members, initiate a break): What we’ll do at this point is take a short break with some deep-breathing exercises to relax those who have shared so far and for those who have not yet had the opportunity and may be getting a bit apprehensive about sharing.  So to begin let’s just close our eyes for a while and focus on a very safe place we have visited or would like to visit, it can be anywhere you want as long as you are feeling peaceful and relaxed.

(The GF gently touches the CD player and calming music filters out, soft orchestral slow tones mixed with bushland sounds of birds chirping and the sound of water trickling along a stony path).  “Many groups, particularly those with members suffering from high levels of mental and/or physical stress, find it useful to include periods of time devoted to relaxation.” (Brown, 1994)

Break for Supper

Two members head outside to the street to have a cigarette and when they rejoin the group they have brought in the two other members who were late because they got “side-tracked”. Curtis and Stolli have stated that they would like to join in because they’ve heard this is a group to help them get off drugs. Stolli states he wants to bring his girlfriend Chloe in who is waiting outside.

The facilitator settles the group when the members become quite agitated at this turn of events. The two new people have the procedures and rules of the support group explained to them. They must make an appointment by phoning the office the next day during business hours and they will be quite welcome to join in with the next lot of participants in four weeks time.

The first Monday of every month is designed for new members joining. This way the previous participants can continue with the support group however they must make allowances for the new participants as they arrive.  Under no circumstances are there to be anyone joining the group who is presently using any type of illicit drug.

Curtis and Stolli appeared to be using some stimulant and this created chaos with the members in attendance. This only enhanced their craving which endangered their safety and sobriety. They had come this far and having people join in who could possibly sabotage their safety was beyond their expectations.

Curtis and Stolli are not permitted to join in halfway through the group. This is a serious exercise for the participants who have made quite an enormous decision to participate in a group that has the potential to change the shape and destiny of their lives as they know it. 

Effie has been quiet up to this point and just as the time came for her to disclose her story, Jasmine who was sitting beside her and beside the counsellor/facilitator, jumped up and screamed pointing to Effie’s shirt. With this loud interruption from Jasmine who had sat silently the entire time, created havoc in the group. The participants all jumped around not knowing why they were jumping around, some almost in a state of panic. 

It took some time to settle the group and it was revealed that Effie had brought her pet rat along inside her shirt for comfort. She was so attached to this pet that she did not want to leave it at home for fear of its safety. Jasmine hated crawly things she stated and said it was ridiculous that this girl should have this rat in the group. Trying to calm the group once again, the GF asked what the rat’s name was.

There was quite a bit of discussion around Effie’s pet rat with a suggestion being offered that members bring along photos of their pets for the following week. Unfortunately Effie’s pet rat would have to stay at home through the following support group evenings and enjoy his time out. 

Time for Jasmine (the group’s quietest member). She disclosed that ever since her husband had died five years previously she had used alcohol as a sedative to help her sleep. The alcohol had allowed her to block memories of him dying in her arms and all other previous memories that led up to that time and since that time, so that each day merged into the other.

Last month she made a promise to one of her sons that she would stop drinking before his wife had their first child. She stated she did not wish to elaborate at this time, for fear of losing control of herself and ending up a blubbering mess.

According to Parkes, et al. (1996), “Some group leaders adopt a structured approach, moving from the discussion of facts, to thoughts and then feelings about what happened.  We prefer a more spontaneous approach, allowing group members to decide upon the group’s priorities and intervening only if the group becomes bogged down or dominated by one particular individual or faction. It is important that everybody has the opportunity to be heard, even though some may prefer to remain silent.”

Conclusion

GF: Thank you all for sharing; this has been a tremendous first night. We will meet again next week as planned, please be on time because the two hours fly by so fast.

And now to end this session of group work let’s conclude with the Serenity Prayer.

You may wish to join in as you remember the words:

“God grant me the serenity to accept the things I cannot change, courage to change the things I can, and (the) wisdom to know the difference.” (Niebuhr)

Reference List

1. Brown, A. (1994). Groupwork (3rd ed.), London: Ashgate Publishing Ltd.
2. Parkes, C.M., Relf, M., & Couldrick, A. (1996). Counselling in terminal care and bereavement. UK: British Psychological Society.
3. Posthuma, B. (1996). Small groups in counselling and therapy: Process and leadership, (2nd ed.), USA: Allyn and Bacon.

Related Case Studies: Case Management of Anxiety and Stress, A Case of Social Anxiety, A Case of Low Self Esteem

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