IICP College

BA (Hons) in Integrative Counselling and Psychotherapeutic Studies

Name of Student Malgorzata (Gosia) Siwek

Student Number 2000492

Module Lecturer Clair Bel Maguire

Module Title Advanced Practice Issues

Date Assignment Due 15.11.2021

Date Assignment Received

by IICP
Received By

DECLARATION:
I hereby certify that this material, which I now submit for assessment on the programme
of study leading to the award of BA (Hons) Degree in Counselling and Psychotherapeutic
Studies, is entirely my own work, devised specifically for this programme, and has not been
taken from the work of others save and to the extent that such work has been cited and
acknowledged within the text of my work.

Student Signature
(Hard Copy Only)
Date Submitted

Grade Awarded

Lecturer’s Signature

Date

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Holistic healing journey

Introduction

This case study is an account of a healing journey that I went through with one of my
clients I was working with face to face for over a year. It was for me a great learning curve and
a chance to test all my theoretical knowledge as much as developing a therapeutical relationship
to benefit the client. I was aware of my responsibility to identify all ethical and practical
challenges and attend them as needed, as much as finding the deep routed causes of the clients
discomfort hidden behind the presenting issue.
In my style of counselling, I was integrating various theoretical models and practical
interventions as a response to needs of the moment. I noticed value of Gestalt and bringing the
client to the present moment by focusing them on the body sensations to re-establish the
connection to emotions. Empty chair interventions, that facilitated client’s processes. Positive
transference and mindfulness techniques. I, also, included CBT elements by giving homeworks
and tracking the client’s progress and Satirian ‘Confidence Pot’ exercises, that give much
clarity for the client understanding of self. Yet, what stroke me as most beneficial, was
Rogerian unconditional regard, congruence and empathy, that I re-discovered recently and
established as the most significant element of my therapeutic approach.
For the sake of confidentiality I will be referring here to my client as ‘Lisa’ using a
fictional pseudonym referring to her.

The Client

Lisa, 27 year old office worker, came to me with a presenting issue of low self-esteem
and low trust in her partnership due to past hurts being cheated on in previous relationship. On
our first session she was sitting in her chair in a closed posture with arms and legs crossed in a
gesture of seeking protection indicating high emotional pressure and disconnection from
experiencing it. Lisa’s presenting issue was low self-esteem and relationship problems. She
was referred to me by her GP, that knew her family well and decided she needs a psychological

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support. As he did not give any direct diagnose I decided to investigate the matter gradually
through interpersonal inquiry not any designed tool like CORE-10. As I discovered after few
sessions, the main cause for her low self-esteem was not her relationship with previous partner,
but learned pattern in her childhood growing up in an alcoholic family. I noticed, that part of
Lisa’s true issue is that she cuts herself off from experiencing emotions treating them as
something unacceptable, trying to intellectualise her problems instead. Practically that meant,
that she was emotionally unavailable in relationships, wanting intimacy but being scared of it
at the same time. This ongoing self-sabotage tendency, causing her more and more distress,
closing the vicious circle of more guilt and shame for being, who she was. That in turn resulted
in even lower self-esteem and confirmation of negative self-believes not experiencing intimacy
in relationships. That is why she started escaping into alcohol to numb herself further. This is
how I discovered, that she is starting to repeat the pattern of her parents alcoholics as a reaction
to her own life challenges.

Substance use disorders (SUDs) are described as ‘a cluster of cognitive, behavioural,

and physiological symptoms indicating that the individual continues using the substance
despite significant substance-related problems.’ (APA, 1993, p.483). That develops ‘(...)
maladaptive patterns of substance use leading to clinically severe impairment or distress.’
(APA, 1993, p.483). It is all due to the process of activating the brain’s reward system while
substance abuse, producing feeling of pleasure or euphoria, often described as high. The feeling
of reward experienced by people when taking the substance causes ‘(...) an underlying change
in brain circuits that may persist beyond detoxification, particularly in individuals with severe
disorders. The behavioural effects of these brain changes may be exhibited in the repeated
relapses and intense drug craving when the individuals are exposed to drug-related stimuli.’
(APA, 1993, p.483). This reward system is similar across all substance abuse. The results of
that may be so profound, that people neglect their usual activities in favour of substance abuse
causing distress to themselves and their environment, often losing control over their lives and
duties as well as their sense of industry. That may ‘potentially affecting physical or
psychological functioning; personal safety; social relations, roles, and obligations; work; and
other areas’ (APA, 1993, p. 485).

The DSM 5 recognises ten separate classes of drugs linked to substance-related

disorders. They are: alcohol, caffeine, cannabis, hallucinogens (phencyclidine or similarly
acting arylcyclohexylamines, and other hallucinogens, such as LSD), inhalants, opioids,

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sedatives, hypnotics, or anxiolytics, stimulants (including amphetamine-type substances,
cocaine, and other stimulants), tobacco, and other or unknown substances.

Important fact is, that people are not all automatically or equally vulnerable to
mentioned substances or to develop substance-related disorders. Some present lower levels of
self-control, that predispose them to develop addiction, when exposed to drugs. This
predisposition can be both: genetical and mental. ‘Family, twin, and adoption studies indicate
that genes and environment have etiologic roles in the development of alcohol and drug use
disorders.’ (Wilens, Yule, Martelon, Zulauf, and Faraone, 2014, p. 440).

There are two groups of substance-related disorders: substance-use disorders and

substance-induced disorders. The first is substance-use disorders, that represent patterns of
symptoms resulting from the use of a substance that one continues to take, despite experiencing
problems as a result.
The second is substance-induced disorders, that include intoxication, withdrawal, and other
substance or medication-induced mental disorders. Substance or medication-induced mental
disorders are mental problems that develop in people who did not have mental health problems
before using substances.

There are many criteria for defining Substance Use Disorders [SDU] through the
problems they cause for the person abusing any of the mentioned substances. We can list eleven
of the main ones: taking the substance in larger amounts or for longer than intended, wanting
to stop of cut down but not being able to, spending a lot of time acquiring for, using, or
recovering from the use. Cravings for it and experiencing urges to use it, not having power to
face everyday duties at work or home, continuing to use, even proven harmful to oneself and
environment ‘Low self-efficacy to control drinking was strongly related to increased alcohol
problem distress.’ (Cellucci, Krogh, and Vik , 2006, p. 431). Quitting previously valued social,
occupational, or recreational activities due to substance use, using substances realising the
danger of doing so, continuing to use despite realising all negative consequences mentioned
‘(...) individuals with alcohol problems do not seek professional help is their stated preference
to handle the problem themselves.’(Cellucci, Krogh, and Vik , 2006, p. 430). Needing more of
the substance to get similar effect (building up the tolerance) and developing withdrawal
symptoms to taken substance.

According to DSM 5 the severity of the SUDs can be specified the number of symptoms
identified in a person abusing a substance. Two or three symptoms indicate a mild substance

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use disorder, four or five symptoms indicate a moderate substance use disorder, and six or more
symptoms indicate a severe substance use disorder. Clinicians can also describe additional
states ‘in early remission,’ ‘in sustained remission’, ‘on maintenance therapy’, and for certain
substances ‘in a controlled environment’.

Therapeutic Approach

To assess the Lisa I used DSM-5 Substance Use Disorder Assessment, on which she
scored 2-3 symptom indicating mild substance use disorder.

Keeping in mind various factors of contributing to Lisa’s arising problem: biological,

psychological, developmental or simply environmental, I decided to take holistic approach to
her healing journey, working on developing with her healthy comping strategies to lowly
replace the need for alcohol as the soothing and numbing substance.
From biological perspective states, that alcoholism is heritable, as the substance affects
the central nervous system increasing susceptibility to addiction in children of alcoholics.
‘There is consistent evidence from family, twin, and adoption studies for the existence of a
genetic contribution to the etiology of alcohol dependence’ (Ehlers, Walter, Dick, Buck, and
Crabbe, 2010, p.185). We can observe ongoing research on all type of risk factors related to
neurotransmitters and sensitivity to alcohol in cases of children of alcoholics.
Psychodynamic perspective gives explanation of childhood trauma on two spectrums:
overprotective mother or maternal neglect, which results in repression of painful conflicts
around dependency needs, that developed especially in oral stage of child’s development. ‘Data
has indicated that childhood or early onset BPD is particularly related to a high risk for SUD.’
(Wilens, Yule, Martelon, Zulauf, and Faraone, 2014, p. 440). That conflict surfaces when in
stress, giving symptoms of depression, anxiety and hostility. In that case, substances are used
to release inner tensions by obtaining oral gratification, satisfying dependency needs. Also, in
cases of anxiety and depression, substances are used to self-medicate.
CBT perspective on the other hand explains SUDs with social learning approach.
Addictive behaviour is learned through interaction between the child and alcoholic parent or
any individual and their social environment. Only by understanding the connection between
thoughts, feelings and subsequent behaviours, triggers to change can be identified to secure
healing. CBT relies on relaxation techniques as a support. Also, skills development process

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and modelling. CBT is often used as part of the treatment, in combination with other
approaches.
In terms of treatment, we may observe two main models in practice: Harm Reduction
Model and Disease Model. ‘Clinicians tend to focus on symptoms, whereas for clients,
symptom management is a means to an end: optimal well-being' (Laudet, 2011, p.46).
Examples of Harm Reduction treatment include addiction counselling, residential treatment
programmes, detoxification, medication (Lithium, Antabuse, Naltrexone), psychotherapy,
group support, and Twelve Step Groups and Programmes (AA, Alanon, ACOA, Alateen,
SMART Recovery etc).

In Disease Models, addiction is seen as abnormal cravings for alcohol and drugs, and lack of
control, not caused by another condition. This model sees disease as irreversible, progressive
and chronic, that if continued, leads to the fatal end. From that perspective keeping abstinence
from the substance is seen as only possible treatment. ‘Substance abusers seek help quitting
drugs not as an end in itself, but as a means to escape these negative consequences and to gain
a better life.’ (Laudet, 2011, p.44). What we can expect from the person in the recovery process
is fragile sense of self and black and white thinking, racing thought and not able to think in a
systematic way. People recovering for the substance abuse will have trouble with impulse
control and delayed gratification. They as well will need support in learning to identify feelings,
and dealing with emotions, when experiencing immature reactions to interpersonal difficulties
and struggles in decision-making process.

I understood, that Lisa is trying to bypass her problems and feelings by soothing herself
with alcohol when the emotions become ‘too much’. As she saw in her childhood, in her family
of origin, the alcohol was treated as ‘a solution’ to that, so she unconsciously started to replicate
it. Her tendency, however, still was presenting as mild, we took a stance to address it and help
Lisa face both her life challenges and solutions to them in a different way. Because of the mild
form of the addictive behaviour I was approved by my supervisors to work with her.

I started from by firstly engaging her with her own body to create bridge into the
understanding of her emotions through bodily reactions using Gestalt methods. I was hoping it
may create curiosity and openness towards self-exploration of her emotions, both pleasant and
unpleasant ones. In the meantime, I was open to hear the client's narrative to fully understand
her life situation, environment and her life path to date, giving us a chance to establish trust
and build up relationship. The client at the beginning was very fixated on receiving

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‘techniques’, that will help her to ‘fix the problem’ of low self-esteem and upsetting thoughts.
Understanding, that this is an innate craving for a ‘quick fix’, I was instead trying to excite Lisa
with the perspective of building up internal strength and listening to most inner needs, that will
result in higher self-esteem. I wanted to dial her expectations toward long-term benefits rather
than counting on an easy fix.

Additionally, I used a form of CBT with Lisa, that she resisted at first and later on liked
more. I asked her to start journaling her states of mind throughout the day to start to get in
touch with herself becoming familiar with emotions rather than running away from them. After
some time, I asked her to start journal in the moments of craving, navigating true feelings and
needs behind the habit of ‘numbing’ herself. With time she made impressive progress in self-
awareness thanks to that. I add to it ’Delay, Distract, Decide’ protocol, in which the client
started to regulate the time between the craving and the behaviour (by going for a walk, call to
a fiend, meditation, cooking, journaling, glass of juice etc…) becoming more and more
empowered and conscious in that process.

Mindfulness practices become one of our biggest ‘friends’ on this journey. I asked Lisa
to first start becoming aware of ‘NOW’ for 1-2 minutes in the morning and in the evening, and
then few times per day, trying not to judge the thoughts and feeling but rather to notice them
and let them play out for a little while with acceptance and self-compassion. That made her
more relaxed into the process she started to observe in herself and let the healing take place
with much less resistance. Naturally she was experiencing fears and resentments towards
herself and others while finally noticing the emotions, but exactly that in time helped her to
acknowledge the reason for her pain and stop fighting the symptoms of it but work with the
cause openly. In order for her to realise some of the patterns, that keep her in the status quo, I
used the empty chair technique often as interventions encouraging her to explore ’how would
it be to say, name, voice etc..?’

At the later stage I decided to use a Confidence Pot exercise to explore ‘drainers’ and
‘fillers’ of it, helping Lisa to navigate her private and professional challenges.

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Interprofessional working

I was receiving support throughout the journey with Lisa. My Counselling Centre was
offering group supervisions, I had my personal supervisor and additional external peer
supervision group. I had many occasions to explain the case, my dilemmas and possible ideas
for the treatment. I often noticed how precious this process was. On my one-to one I was often
exploring my fear and prejudices that could have affected my judgement and on group
supervisions I often took on the perspective or suggestion of other fellow counsellors, that was
sharing different way of looking at the problem. I noticed, how other styles of therapy
represented by other practitioners were adding to the way I am leading the healing journey with
Lisa and I learned great deal while listening to them offering their distinct solutions and points
of view.

The support of my supervisor was especially valuable whenever I was forming next hypothesis
or choosing a form of treatment for the next stage of Lisa’s healing journey. That definitely
helped me to assist Lisa’s major breakthroughs. I received valuable pointers concerning
possible interventions, that I applied in later sessions.

Mental Health Promotion Intervention

I had most sessions with Lisa face to face, however we tried for a few weeks the phone
therapy during the first few months of lockdowns. The experience was different but I can surely
say it was equally beneficial for Lisa.

Face to face contract included the way we work and meet, mutual confidentiality on
what was happening in the room, my limits of confidentiality as a therapist, and rules around
keeping the time. Yet, working on the phone I had to point out other additional factors. I asked
Lisa to always have a place, to call from, to herself with no people that could overhear us. The
fact she can feel safe to talk was a priority to me and wanted her to feel it. That additional
devices she has around should be put off, as they may sometimes bridge the confidentiality
with recording or ‘listening’ functionalities installed. I was keeping these percussion on my

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side as well, preparing a room, where nobody will disturb me and I have full attention for the
client in the most optimal set up.

Over the phone I wouldn’t use interventions, that included reading the body language
an keeping the eye contact, but I noticed that narrative therapy and mindfulness explorations
were even more effective as the client was in her own environment, where she could relax in
her own environment. I also got the impression, that she found it even safer as she didn’t need
to analyse projected reactions of me and instead kept focused on her own experience while in
the process.

Yet, I realised as well the necessity for more frequent reassuring her of my presence by
increasing effort in presenting active listening skills, i.e. adding ‘yes’, ‘right’, ‘wow’, or
mirroring of what she is referring. As much as me depicting for her my reaction like: ‘you
know, when you said that I felt how lonely you must have been feeling, I even changed how I
sit…’ That kept her confident in me assisting her process in place of me being next to her
physically. I became creative in inventing visually stimulating vocabulary, that helped in
deepening the trust in our therapeutic relationship. For that reason I put extra attention to show
my empathy though verbal remarks and sounds, making sure the client hears my support,
approval or lack of judgement depending on the need. I understood she needed it, as that I have
to replace somehow my reaffirming face expression. I am convinced she felt my empathy,
congruence and positive regards all along.

Ethical considerations of working online

When working with Lisa I was keeping in mind few other macro and mezzo aspects, that could
impact Lisa in her circumstances and me as a professional facilitating her opportunity to receive
adequate help. I was investigating, if she is not in a vulnerable life circumstances due other
social standing or income, if she is not having family members, that require additional needs,
her sexual orientation or a religion as a contributing factor etc…

I was happy to being able to support her in the counselling centre, that admits clients from
unprivileged backgrounds and financial standings. I only wish for the widely available access
to mental health opportunities to all poor families in Ireland and outside, as the poverty proves
to be most challenging factors for human development and mental health in general. I will be

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advocating for it as currently these opportunities are facilitated mostly by non-profit
organizations. In my opinion the policies should be adjusted to provide this help to those who
need it but cannot afford it.

I also want to make a difference by being the counsellor, every client, from whichever
background feels supported and appreciated by. I also want to contribute to the social justice
within the wider society by forming and joining communities that advocate for easier access to
mental health and self-empowerment for those who need it. Just as I observed in Lisa’s
behaviour a change after we started to apply methods identifying her strengths and changing
her self-talk, her relationships and self-image changed, giving her more freedom in choosing a
life she wants to live. I cannot overestimate the power of psycho-education in transformation
of the world’s paradigm, especially, if a person comes from very challenging background. Also,
after the self-transformation, the client can become the example and an inspiration for others
going through same process. This change reaction, if properly fostered, can bring macro
transformation to our society in relatively short time…

Also, while working with Lisa I was self-examining, whether any of my biases or about
alcoholic families are impacting my therapeutic relationship. I was supported in my reflection,
especially by my group supervision, when I was sharing the Lisa’s case and listen to the other
practitioners’ ideas and points of view, to verify mine.

Although, Lisa’s alcohol problems at that stage were not severe, if we were to work online, I
would still encourage her to access alternative medium of support.

We are fortunate to have face to face sessions mostly, however, if we were to have online
therapeutical relationship I would still try to meet at the beginning for the initial assessment of
the client’s appropriateness for online therapy, their remote environment, crisis management
and contacting around backup communication strategies in case of network failure (APA,
2013) and how we would be communicating in such case. I would include in the contracting
aspect of safety for the client: where should she be sitting, how to provide her both feeling of
safety (private and comfortable space) and safety itself: if in the car, then not driving and
making sure all recording devices (like dashcams, Siri, Alexa) are switched off and no
passengers inside to make sure the client has safe and interrupted space to work. Also, how we
will be agreeing on adjustments along the way. I would make sure to use a recognisable,
security-aware platform to ensure good quality internet connection to provide most stable
experience.

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Also, I would be very mindful to not allow technology to overwhelm the therapy process, and
stay focused on the needs of the client.

However, meeting the needs of the client shouldn’t be compromised by the lack of boundaries,
so I would be agreeing about the time and manner of our exchange between the sessions or the
approach to interruptions withing a session by the family members, phone etc… as much as
rules around going over time. Rules around potential bathroom break or urge to get a drink
would be very helpful too. Also, very important is not giving the client opportunity to record
the session and share it outside without my consent for the benefit of the process and mutual
respect. As well, I would advice a proper firewall and other percussions around the data security
and agree on the rules around payment for the sessions. I will consider also my privacy in this
relationship, as how much of my environment I want to make visible to the client during the
session and what type of background to put as most suitable for the therapeutic relationship.

Another important aspect I should be mindful in the future is various laws for different
countries in case of working with clients abroad around definition of minor and adult and
potential need for the parental consent. There are also distinct laws and regulations worldwide
regarding online counselling and data-protection (like GDPR) I should be mindful of them
before admitting the client from abroad. Equally I should confirm with my insurance provider,
whether they cover for online counselling outside of Ireland.

Another important aspect is to be aware of how long should I keep the data for, which measures
should I apply to protect it (password, software etc) and how will I erase it. For that I need to
be constantly in touch with both my insurance company and my ethical body (IACP 7 years)
and include this information to the contract before the therapy begins, collecting all the
necessary personal information, next of kin, in case the client needs immediate support, or
professional contact in the event of safeguarding issues.

Reflection and critique

Throughout the healing journey with Lisa I realised the power of empathetical presence
as most essential and impactful in fostering breakthroughs for the client.

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 It was not the academic knowledge that was most helpful but the relationship and
authenticity in it, that served the client most. Thanks to support of the supervisors I was able to
use mindfulness to stay present and let the client’s need lead the session, not my ideas for the
next intervention. In that process I learned a lot of humility and respect for the client. Thanks
to that I became more present to what was unfolding here and now between me and the client.
I realised, that the client senses, when I am there with undivided attention, and she feels more
open, trusts the process becoming more honest with me and with herself being able to risk new
behaviours. With time, she begun to use the learnings, mindfulness techniques and staying in
the emotions diminishing her use of alcohol and replace it by other activities like: journaling,
cooking, calling a friend, meditating etc. That in turn gave her more feeling of power over her
life and started raising her overall self-esteem.

Since the client is more or less my age, we have been quite informal from the start. I
noticed, however, that in times, the client was looking up to me, as an authority, which is on
one hand useful for her to trust the process. Yet, I had an impression, especially at the beginning
of our journey, that Lisa wanted to give her power away to me as someone, that can ‘give her
the answer’. For that reason, on many occasions, I emphasising her power, for example by
asking, ‘how do you think it impacts you?’ or ‘what do you think is the best thing to do here?’
etc. It was however tempting for my ego, but I did not want to deprive her of her own power
so I was redirecting it back at her. She is the one who knows the answers, not me. I am to help
her find it. That was a great learning for me, how is it in the moment to direct expectation and
transference, realising potential consequences for the clients, myself and our therapeutic
relationship. This transition from seeing me as an external authority and looking for the easy
solution by following the process to equal relationship, with developed sense of Lisa’s power,
was one of our successes.

Also, my supervisor and supervision groups, helped me to encourage Lisa in developing

practical ways of expressing needs and objections in a way, that is safe and timely, before the
pressure arises and becomes incontrollable. Now she is able to express her needs in
professional relationships now much more successfully. All of it empowered her sufficiently
to become ready after 14 months of working together, to take her learnings and use them
independently in her life. Together with Lisa and my supervisor, we decided, that it is a good
time for her to leave the therapy.

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 What I could have done better, was being more present during sessions, especially for
the first 6 months, when I was more thinking and proving, than being. I know it is my general
tendency. I find awareness of that most helpful in the process towards changing it. What helped
both of us was mindfulness practice, that helped Lisa staying connected with herself
diminishing in time her craving for the alcohol in stressful moments and me staying present
with her in ‘here and now’.

Also, I wanted Lisa to get feel more empowerment soon, I was exploring new ways of
helping her in between our sessions, but then I realised that it may be my controlling tendency
trying to ‘speed things up. I was bringing it to the supervision to be able to make best choices
for the client and to become more self-aware as a therapist.

Conclusion

Working with Lisa gave me many opportunities to explore my abilities as a counsellor

and to work with other professionals and my supervisor. Through that process I had a chance
to test my theoretical understanding of low self-esteem and addiction and practical application
of the treatment, which at the end had more to do with therapeutic relationship and mindfulness,
than all academic knowledge I was faithfully absorbing for the past years. I have learned to be
more present through active listening, mindfulness and openness to the client’s needs of the
moment.

In the online setting some of the methods to deliver therapy differ and change, but the
general logic and purpose for these stay relevant despite the overall world transformation. I am
determined continuously be mindful of the ethical and legislative challenges related to online
therapy to bring most benefit and safety to my future clients. Yet, in my observation, nothing
ultimately can ever replace human empathy, authenticity and unconditional regard, that yield
trust and create conditions for powerful healing transformations.

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