EXAMPLE ANSWER: VIGNETTES

VIGNETTES

Case Study one: You have an appointment with a new client, Mark, who has booked in for smoking cessation. Your client, Mark, enters the practice and you engage in small talk about how he travelled there and you notice there is no eye contact as he continues to look down most of the time. The conversation then turns to the reason for his visit and what you may be able to help them with and the reply comes back, “I don’t really see the point anymore, I am too tired to carry on”, or “everyone would be better off if I was not here”. When asked how long the client has been feeling this way, it transpires that his wife recently left him and she has begun divorce proceedings. It is likely to be a prolonged battle over assets and child access. He volunteers that he feels he has not slept well for weeks and is alternating between being tearful and irrationally angry. Discuss how would you deal with this client and any associated issues.

(Student answer here) Ideas how you would proceed i.e. suitable intervention, ethical complexity, referral etc. In order to work with Mark at this point I would be honest and open and I would question whether stopping smoking at this time is actually desirable or achievable in the light of what he has told me. Ideally I would see if he would consider continuing the session on a different subject- one in which the other issues he is experiencing could be explored and if he would consider a future session. If he is agreeable to this I would explore what areas he would like to work with – bearing in mind that I would also be concerned about the comments he has made about being “too tired to carry on” and “ everyone would be better off if I was not here.” I would ask Mark if he has been in contact with his GP and ensuring that I have contact details for his GP. Agreement to a future session and seeing his GP might help to allay some of my fears but if these increased to a stage at which I was concerned about his or others safety I would contact his GP and if necessary the Police and report my concerns as an issue of safeguarding and protection. This is especially important if he has access to his children or expresses anything that would cause alarm –whilst not wanting to be alarmist a man going through a relationship break-up with fears about custody and expressing these views may be more likely to consider harming their family. If Mark and I were able to establish areas to work on and were able to develop rapport, I would aim to work with confidence, control over anger and increased feelings of self-esteem. I would establish areas in which he does have some control and methods in which he has established control previously. I would be looking to move him from the top down global approach into a more focussed look at the areas within his life – what is important and how he can use his own resources to create this. It may be that sleep is another area that could be examined – the impact of having a good nights sleep after which he can feel rested and ready to address the issues which are coming. The content of the meta-analysis would dictate the method used but it should include future pacing where he is able to experience positivity and change. During the session I would be paying close attention to Mark’s responses and reported changes/experience. I would be booking the next session and ensuring that Mark was aware of the ways in which to contact me if required.

Tutor feedback (DO NOT delete/edit feedback. Write amendments, additional information & thoughts underneath this table) Correct. I am pleased you will take this approach if a client confides such things and that this would trigger such response from you. Whilst there are many who would shirk the responsibility, passing the client on to others or flatly refusing treatment, I am confident and pleased that there are now therapists such as yourself who have the ability to help effectively in such circumstances and take the necessary steps. We at Unity thank all ‘unwanted behaviours’ that bring a client through the door. After all, referring back to secondary and tertiary gains, the smoking behaviour (like other behaviours the conscious mind suddenly deems unfavourable) are serving some important purpose in the client’s life and merely ‘taking the dummy away’, particular at times like these, is maybe not advisable.

Further example answer:

I personally would not normally work with a stop smoking client.

Having obtained a good level of rapport I would use meta-questioning get the client to expand on their opening comments to establish a better understanding of the client's current frame of mind as well as identifying the right steps to assist him in the best way possible.

I would look towards gaining permission to work with the client on his other issues rather than the smoking during this session, I would inform the client I felt stopping smoking at this time unproductive due to all the other issues currently in his life, as I would consider them more important.

If the client is agreeable to continuing with this new direction of the session I would want to work with his self-esteem and confidence issues as well as stress release as he appears to be struggling with these at this time and assisting with his poor sleep issues, which should have a beneficial effect on him generally.

Utilising the Control Room to adjust his Subjective Levels of Discomfort and directing his sub-conscious mind to resolve his stress related issues as best as possible with a strongly anchored quality sleep suggestion incorporating Reframing of his future, possibly utilising Parts Therapy if I discovered it to be appropriate during the meta-questioning.

I would request the client had at least another session preferably within a week to monitor and support them whilst ensuring sustained progress.

I would closely monitor his behavioural changes (both during the session and after) to make an informed decision as to the next step.

I would strongly consider the client's true intent, bearing in mind his comments of “too tired to carry on” and “ everyone would be better off if I was not here”, should I consider these statements to be more than a throwaway comment I would try and persuade the client to contact his GP and discuss how he is feeling, if I felt it necessary I would contact the GP myself to report my concerns as required under the Code of Ethics.

A good assessment of the situation here and a clear and concise plan of action both of progressing with the therapy session and the various implications. Though there really are no right or wrong answers here, it is a good approach, as you say, to avoid dealing with the smoking cessation at this initial stage, when it may be a supportive mechanism necessary to his well being at present.  

VIGNETTES

Case Study two: Mary arrives at your practice for help losing weight. In your pre-talk she comments angrily about the behaviour of her nine year old son, Josh, who never does anything she asks. She has been a lone parent for over a year since the break-up of her relationship which she blamed on Josh’s bad behaviour. She says she is at her wits’ end and does not understand why he is so badly behaved. She admitted that he angered her so much one night that she even threw an empty bottle in Josh’s direction when he particularly upset her. As you ask about her eating habits etc she volunteers that she and her son live on a diet of fast foods which are delivered to the home as she never has time to shop or cook properly because her job involves long hours, where she is not home until late, and it is very stressful. She then tells you that she cannot sleep unless she drinks at least a whole bottle of wine every night. Discuss how would you deal with this client and any associated issues.

(Student answer here) Ideas how you would proceed i.e. suitable intervention, ethical complexity, referral etc. If Mary were to discuss these issues with me I might assume that we have developed a level of rapport. It is clear from what she has said that there are issues other than weight loss and at this stage I would be honest and open about this – it seems that there are other areas which may be impacting. However I would also accept that weight loss may be the area of her life in which Mary has decided she may be able to assert some control. Ideally I would see if she would consider continuing the session on a different subject but by sensitively raising the issue it may be that the focus changes anyway. However at the same time I would have significant concerns about Josh. I would ensure that I have contact details for Mary’s GP and I would be asking if she has been in touch with the GP and what other areas of support she has (familial, Social Services, school….). I would need to know who if anyone else is in the house at night as drinking a bottle of wine every night may mean that Mary is not in a position to be responsible for Josh. If my concerns increased to being concerned about Josh’s or Mary’s safety I would contact the GP and if necessary the Police and report my concerns as an issue of safeguarding and protection. In order to work with Mary there are several areas in which she may wish to address and which also may be intertwined. Alcohol and the consumption of empty calories within alcohol may be addressed in the guise of weight loss. She may wish to focus on sleep, anger management, ways in which she can take control of areas of her life…. The content of the meta-analysis would dictate the method used but it should include future pacing where she is able to experience responding differently to food and perhaps a future in which she is able to eat healthily and the changes which would need to take place for this to happen (planning, time, calmness..) During the session I would be paying close attention to Mary’s responses and reported changes/experience. I would be booking the next session and ensuring that she was aware of the ways in which to contact me if required.

Tutor feedback (DO NOT delete/edit feedback. Write amendments, additional information & thoughts underneath this table) Correct. You are right that a good level of rapport would have to be established in order for these vital elements of the client experience to be revealed. However, this is also an indication of the severity of a problem – hence some folks who seem to tell tales of their doom and gloom to almost anyone that will stand still long enough; the lady in the post office or the guy trying to sell her windows. In each case of course it is a cry for help and how you respond to that is variable. It is a factor of the business of hypnotherapy that people will come to see you under the premise of ‘losing weight’ or stopping smoking etc and whilst some serious professions see that in a negative light, wishing we were called upon to treat more serious issues, it can also be seen as a positive in that if they didn’t smoke or have weight issues some clients would not walk through your door. These are perhaps the same clients who would never think of seeking professional help until some larger marker indicates that they needed to. I appreciate also your understanding that the weight control is maybe part of her life that she can learn to exert some control. I go back to the days of watching psychiatric patients do basket weaving and artwork and the recognition if we can have control and creativity in some matter of complexity then the ability to do that with basket weaving deftly begins to flow into other areas of life where it is necessary to respond with such abilities. There is also the question of blame frame. This is a big concern. It is fundamental to her relationship with her son that this be addressed. ‘when HE particularly upset her’ is a marker to recognise that she maybe needs to be beyond this sort of upset. If a child can so upset a parent that the parent turns to physical violence, then the work is to deal with the parent’s reaction to previously upsetting comments. The words and phrases and actions of other people which result in an individual been driven to violence are the keys and the vehicle to free them of further upset. These triggers can return a client right the way back to a moment of hurt when the partner or, indeed, THEIR parent said such things. Regression happens spontaneously in such circumstances; one could say that in the moment she threw the bottle she regressed to a poignant moment in the past, so formal therapeutic regression may be an answer. In summary, such revelations that the client makes that you are privileged to hear and respond to are gifts handed to you on a plate for you to craft your way into helping them and choosing your interventions and overall approach. If you can test your work afterwards by using the same triggers that the boy used ‘to upset her’ and she is no longer upset or regressing to some past pain, you have resolved the conflict. Weight control is perceived by the public to be a long term issue, whereas smoking is still thought to respond to the ‘one hit wonder’ approach which we discourage. Therefore, there is opportunity to work with this client by incorporating some weight control management techniques into the first session (as it is the reason she has come to see you) though also designing a four or six session plan to help her with all related issues discussed above.

Further Student Example Answer:

(Student answer here) Ideas how you would proceed i.e. suitable intervention, ethical complexity, referral etc. Again I would not work with Weight Control Clients. Having obtained a good level of rapport I would use meta-questioning get the client to expand on their opening comments to establish a better understanding of their current frame of mind as well as identifying the right steps to assist them in best way possible. I would look towards gaining permission to work with the client on her other issues rather than the weight control during this session, as I would consider them more important at this time. If the client is agreeable to continuing with this new direction of the session I would want to work with stress release and anger management as that appears to be the major issues at this time and also assisting with her poor sleep pattern, which should have a beneficial effect on her general life. I would consider use some Ericksonian metaphors to work on her acceptance of her current position as I would expect some issues around feeling guilty of her behaviour towards her child which may help to move forward. Utilising the Control Room to identify and adjust her Subjective Levels of Discomfort, directing her sub-conscious mind to resolve the stress and anger related issues as best as possible with a strongly anchored quality sleep suggestion incorporating Reframing of her future, possibly utilising Parts Therapy or potentially Regression Therapy if I discovered it to be appropriate during the meta-questioning. I would request the client had further sessions with at least another preferably within a week to monitor and support them during this vulnerable stage whilst the on-going work would ensure sustained progress. I would closely monitor any behavioural changes (both during the session and after) to make an informed decision as to the next step. I would try and persuade the client to contact her GP and discuss both how she is feeling and possibly helping with her drinking dependant on how dependant she believes she is on the alcohol, the GP could also to identify any assistance there may be available with a reference for her to social services for greater support with bringing up a child under these circumstances. If I felt it necessary I would contact the GP myself to report my concerns as required under the Code of Ethics as her child is potentially at risk of harm should her situation continue un-changed or deteriorate further. A good approach and due consideration of the implications of this complex therapeutic situation with a good regard not only for the well being of the client, but for the child also. The therapeutic structure of the session seems most appropriate and also the follow up and timing of the other sessions. I particularly applaud your recognition of the value of the sleep improvement as the initial step toward an improved condition.

Tutor feedback (DO NOT delete/edit feedback. Write amendments, additional information & thoughts underneath this table) A good approach and due consideration of the implications of this complex therapeutic situation with a good regard not only for the well being of the client, but for the child also. The therapeutic structure of the session seems most appropriate and also the follow up and timing of the other sessions. I particularly applaud your recognition of the value of the sleep improvement as the initial step toward an improved condition.