Social Work Internship: 10th week

This was a busy week with my conducting seven one-on-one sessions, having two intakes, making a presentation to two women groups, as well as attending a seminar on the role of social workers in within the oncology and palliative care arena.

In terms of the individual sessions, two of the seven appointments were with new clients and five were with clients with whom I have been working for several weeks. To my delight, I’m starting to experience some positive changes with some of my regular clients in that we now have a deeper therapeutic alliance and/or that they have begun to grow stronger in some way.

For example, one young male client (let’s call him S) who suffers from an impulsive mood disorder had come in last week and shared two upsetting events at work that led him to feel frustrated and angry. Subsequently, S cursed out one employee as well as a supervisor. I first engaged in empathetic listening; that is, listening in such a way that I was empathizing with the frustration and anger that S felt when the two events occurred.

I then wanted to see whether the client had any mistaken perceptions that were feeding into what had gone on. Hence I tried socratic questioning (a method in which a clinician asks questions to try to guide a client to evaluate his/her assumptions) to find out whether those events that occurred were necessarily directed at S or was it possible that they just happened almost irrespective of him.

To illustrate, a supervisor had asked for assistance from the workers during a group meeting and S had raised his hand to indicate his interest and willingness to help out. Despite the fact that the supervisor had given S the go-ahead, another worker essentially cut S off by jumping in vocally which ultimately prompted S’s angry outburst towards this worker.

The questions I had posed S led to the possibility that the worker did not override S with a personal intention to disrespect and insult S. This is because S was able to share other instances in which the worker demonstrated an excessive need for the supervisor’s attention and praise. However, at that moment in time, S was not able or ready to acknowledge the possibility that the perceived attack may not have been a personal attack.

Instead, S expressed his concern that he may not be able to hold himself back from getting into a physical tussle with the worker the following day at work. As a result, I switched tactics and went back to reiterating how wrong it was for the worker to cut S off but that the approach of cursing that worker was not really the best approach for S to employ in terms of his future and success. I commended S on having held himself back from getting into a physical fight with the worker and asked S what was his overall goal.

S mentioned how hard it has been to hold his temper at work but that he has done so for the past year and would like to get promoted to the next level. I praised S for all his success to date and suggested that he try to focus on that big picture of achieving his goal of getting promoted to his next level and not let the attention-seeking worker derail him from his success. In other words, the recommendation was that S ignore the insignificant worker and focus on working towards his important objective of doing well at work. This strategy seemed to be a potentially effective one because it made sense to S and S then moved on to sharing a second event that had upset him last week.

This week, when S came in, he shared how he had not gotten into a fight with that worker last week. I felt so happy and proud of S 🙂 After praising S, I moved onto explaining the key concepts behind cognitive behavioral therapy (CBT) of how it is our perceptions of events that affect our reactions to those events; how thoughts differ from feelings and how our thoughts affect our feelings which in turn affect our behaviors. Interestingly, S kept on trying to divert me to various health issues in the middle of this.

When I shared this observation with my supervisor, she explained to me that this was resistance on the part of the patient. Resistance evidently often occurs after you have had an effective intervention but the client needs you to slow down. Therefore, next session I will need to stay off topics dealing with his anger management issues and instead cover a subject that will evoke positive safe feelings for him before being able to resume the CBT work.

Moving onto a second client, (let’s call her E), E is a woman whom I described in my post Social Work Internship: 7th Week  before as being rather quiet and uncooperative of late. E came in this week after having missed her appointment with me last week (and as you know, there is often therapeutic significance to a “no show”) and I feel that we had a very productive session.

The session began with my asking E to clarify the comment “I do not feel free,” that she had made during her last session. She explained that while her years of sexual, physical and emotional abuse have finally stopped, it does not feel this way. The years of abuse feel like they are still continuing via her flashbacks and this is why she does not feel free… I learned for the first time that flashbacks (or at least her flashbacks) are actual re-enactments of her past abuses. For E, they feel so real and in the present that she actually passes out to block out the pain as she had done in the past.

To assist E with her flashbacks, I tried reading to her a visualization flashback relaxation script that I found online and had tweaked a little to make it more appropriate in terms of language etc. While she was not ready to trust it enough to close her eyes and relax, she did sit through it and it ultimately helped E to further open up and talk about what her flashbacks are like with me.

It will clearly take much time and effort to help E heal from all the terrible trauma she has experienced; however,  I feel that we made an important first step this week. I also feel that by having found the visualization flashback relaxation tool, I finally have something concrete to offer E that could ultimately help her, albeit very slowly.

The main premise of the script is to eventually see the traumatic event as if on a TV screen and there are a number of grounding steps that you are doing during the exercise such as rubbing your hands and feeling the warmth between your hands that helps you feel that you are here in the present to help differentiate now vs. the past when the traumatic event(s) occurred. To be realistic, I am stressing to the client that even if we are only able to get her to rub her hands once during one of her flashbacks and feel that warmth between her hands, we will have made huge progress.

Finally, with two of the women’s groups that I co-facilitate, my supervisor had asked me this week to put together and present a presentation on panic attacks that occur about going outside/leaving one’s home. To that end, I presented some information about the connection between thoughts, feelings and behaviors, and then about fight/flight response and panic attacks.

I concluded with a relaxation script that I made up in which I was taking them on a bus trip. Thankfully, the group sessions went well. One group liked the relaxation script so much that they asked if each subsequent group session could end with my reading them a relaxation script.

So that’s the update for now. As always, please feel free to share your thoughts and comments below. They are always most appreciated 🙂 I know that I have much to learn and will continue to do so for many years to come…

Photo Credit: qthomasbower
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