Sara and Me
This case example is taken from my work with Sara, a doctoral student in her first-semester practicum experience in our Departmental clinic. Her clients were undergraduate volunteers from several sources, including a course required for students on academic probation.
Some background information.
Sara’s master’s-level clinical internship was in a medical setting, with an emphasis on assessment and referral. Thus, I found Sara’s intake sessions were very strong, as she did not hesitate to ask about sensitive subjects (e.g., history of trauma, suicidal ideation) and definitely had a counseling feel (versus question-answer interview). During this practicum experience, however, she would be able to see clients for multiple sessions and thus have the opportunity to achieve more depth in her work.
Sara was highly introspective and also very cognitive-oriented and focused on achieving her goals. She also could be rather self-critical and had high demands of herself around her work, really pushing herself to grow. Sara described her counseling philosophy as strengths-based and person-centered, although her preferred theoretical orientation was Reality Therapy. Physicality is also important in understanding Sara; she is a personal trainer and highly attuned to body language and facial expressions. Tall and with exquisite posture, she has an “in charge” air, yet her compassion and kindness also come through easily. She readily spoke to her challenges in getting in touch with her own emotions, based in some family dynamics, and clearly understood that this influenced her clinical work around emotions. Accordingly, her initial goals were primarily focused on enhancing her responses to client emotion. She was exceptionally open to feedback and challenges around working toward this goal; in fact, I was very aware that Sara took all feedback to heart and immediately began to act upon it.
Reflecting emotions had been a theme in all of our supervision sessions, such as identifying emotions and practicing reflections of feelings while watching videotaped clips of the counseling session. It was clear through these supervision interventions that Sara had a strong vocabulary of emotion words and could easily identify emotions…when she slowed down and turned down the mental noise in her head. I also had invited her to talk about her vision/image of herself as a counselor and then encouraged her to enact that in session – having a calmer pace, allowing more silence, giving more concise responses, giving less focus to the details of the client’s narrative, and more being present in the room. Sara had certainly made progress, especially around having a calmer presence in the room and a slower pace, but she often still seemed to be primarily operating out of her head.
The focus of this supervision session.
In this case example, the counseling session digital recording (video) that Sara submitted for supervision was her second session with a Caucasian female client who reported a fairly strong relationship with her mother, a tense and rather conflictual relationship with her step-father, and anger about her lack of a relationship with her biological father. The client was quite intense, expressed strong emotions, and tended to tell her stories in a rapid-fire pace. The client was somewhat guarded and readily noted that she avoided her own emotions, although they were sometimes palpable as she shared several incidents from the last week. This was clearly a client who could benefit from Sara’s help, and a client who needed Sara to be the counselor she wanted to be (i.e., lots of opportunities to work with strong emotions, achieve some depth in the work). Based on our discussion of this client in a previous supervision session and my review of Sara’s case notes, I thought she had a pretty clear conceptualization of the client, so did not think this needed to be the focus of our supervision session. Instead, my goal was to help Sara get into the space needed to act on her conceptualization of the client.
In reviewing the tape, I noted that Sara seemed to match the client’s pace somewhat, yet made some appropriate reflections of feeling (that the client did not respond to directly). However, it appeared that Sara’s fast pace affected her tone. For example, her tone in the following sequence was very matter-of-fact, including the bolded reflection of feeling (wording is abbreviated and modified somewhat to protect client confidentiality):
Client:[Story about lack of connection with birthfather] I don’t want this kind of family life for my future kids. So, I will do everything in my power, within my reason, to make sure that doesn’t happen for my kids ‘cause I don’t want them to have to experience that. And say this to Todd [boyfriend] all the time. I don’t want this for my family and he’s – he hasn’t been through that, but he’s gone through a broken home too….His mother and father got a divorce and then she remarried several times. So he’s been through different father figures too, and he loves his stepfather and hates his dad, which makes no sense to me because his dad didn’t do anything to prevent them having a relationship. I tell him, your dad never denied you –
Sara: Unlike your dad.Client: His dad tries to talk to him all the time but Todd won’t talk to him. And his mom was the one who decided she wanted to leave. I asked him, Why are you mad at him? Why won’t you talk to him?
Sara: ‘Cause you wish you had that option.
Client: Yeah, I wish I had that option. I’m just, like, why won’t you talk to him? And that upsets me. His dad is trying. Mine won’t. And even when I try to get information about him, nobody will tell me the real story. My mom won’t, he won’t.
Sara: You’re sad at what you missed.
Client: Yeah….’cause I don’t want that. I just want my kids to have a great future.
So, the reflection was accurate, even naming the sadness under the expressed anger. I wondered if the matter-of-fact, somewhat abrupt tone negated the impact and allowed the client – and Sara – to avoid the reality, intensity, and depth of the feeling. From a parallel process perspective, the client stated she did not want to talk about/experience these feelings, and at some level Sara didn’t want to talk about/experience those feelings. Hmm, a different approach was needed – something other than the skills-focus we had had previously. Something more experiential? I remembered that Sara had written in her preliminary statement of goals that her master’s program had helped her “integrate my underdeveloped softer side” into her strong woman side, and I thought that might give me an entry point.
I saw helping her be the “soft Sara” as the basic, foundational shift needed so that Sara could be really present and aware, recognize and act on opportunities to use immediacy and be able to challenge this client. So, finding, perhaps magnifying, “soft Sara” was my primary goal for today’s supervision session.
I also identified two more skill-based points I hoped to be able to address, based on how long it took to process the priority focus on the emotional issue, and which could help balance out the emotion-focus.
Sara started the session this way:
Sara: How are you today?
Client: Good. Tired.
Sara: So what’s been going on in the past week?
Client: [extensive reporting of several events in some detail – and intensity]
I had noticed Sara begin sessions similarly before but had not addressed this directly. Given this client’s propensity to describe event after event, it seemed important to bring this up in our supervision session.
The following interchange occurred around minute 45, after Sara and the client have noted the client’s use of humor to protect herself from her feelings:
Sara: How’s your energy level? How’s your fatigue?
Client: I’m okay. I don’t know if I’ll be able to go to sleep now, but I’m okay.
Sara: You’ve said that several times. It’s almost like a mantra.
Client: I’m okay. I’m okay. Or I’ll be okay. I can’t not be okay. (some lighter statements with laughter) Like now, I’m okay. I have a headache, but I’m okay.
Sara: Yeah, yea. And you’re – you know, you’re opening up some doors that you had deliberately closed. And that’s hard work. I appreciate you doing the hard work.
Client: I appreciate you ‘cause I didn’t think you were gonna be able to do it – I know parts of me were saying, just like, Client Name, stop talking! (laughter)
Sara: Well, in here you get to determine whether you speak or not, not anybody else.
Client: And I’ll tell you it’s nice that I have an option.
Sara: So what you got goin’ on fun this weekend?
On her tape review form, Sara had written the following self-reflection about this part of the session:
Toward the end of the session, I deliberately came back to some of the seemingly mundane aspects of her initial story, feeling as if it was important for her to know that even after broaching some difficult topics and emotions, she could come back to a place of matter-of-fact day-to-day conversation. This is in part a strategy that I appreciate in my own counseling sessions, when the counselor brings things back to neutral, and honestly, in this session, I had this urge to switch gears so she felt safe (so I felt safe?). Looking back, I wish I had waited a few more minutes.
For me, this seemed more than bringing things “back to neutral” in helping the client feel prepared to leave the session. I wanted to help Sara take less responsibility around this, and especially to find another way rather than chit-chat at the end of a pretty intense session.
So, my plan included addressing these three points in the supervision session:
- How Sara reflected the client’s emotion/inviting “soft Sara” into the room
- How Sara started the session
- How Sara ended the session
(Note. All practicum counseling and supervision sessions take place in our in-house Departmental Clinic. All are recorded via a digital system housed in the Clinic. Both counselors and their supervisors can access the counseling sessions for review in preparation for and during supervision sessions.)
A few caveats before we watch portions of the supervision session:
First, this session took place on a Friday in September and the weather was rather chilly for the season and wet. I don’t usually wear jeans during supervision, but that’s my explanation for wearing them this day – to be comfortable and warm!
Second, when I entered the room Sara was sitting on the floor logging onto a laptop computer to access the Clinic’s digital taping system in case I wanted us to watch a portion of the counseling session recording during supervision. As indicated above, physicality is important to Sara and she seemed comfortable, and I briefly considered sitting on the floor with her, but creaky knees kept me in my chair. I remarked at the beginning of the session that our seating arrangement might emphasize the power dynamic and that we could change if that seemed to be so; it never seemed an issue so we didn’t change during the session.
Finally, this is not an elegant supervision session; as you will hear, there were times I was wordy and wandered (which is a pattern for me), and there were times I interrupted Sara (a tendency when I’m thinking something through and have more to add). I would say it is a fairly typical session in that I had clear goals, had some general idea about how I wanted to address those goals in light of how I knew Sara (e.g., her openness and willingness to explore whatever I brought up, her need to think through for herself whatever I brought up – so I had to provide space for that; her self-critical tendency and my wanting not to encourage that while providing constructive feedback). I do believe the session reflects at least somewhat my supervision approach: developmental and educational, intentional and proactive, supervisee-focused, a balancing of challenge and support, all based in a collaborative relationship. (See Modules 1 and 2) Also, and most importantly, Sara was willing for me to use this session for this module, and gave her permission for you to watch parts of the session. Thanks, Sara!