HUM9997 - SECTION 12: ANALYSIS OF CASE SCENARIOS
SCENARIO ONE
Jeff is a clinical social worker providing services in an outpatient setting. Jeff usually operates from a short-term, but eclectic, therapeutic perspective. He is seeing a young, African-American couple, Wesley and Patricia, for the third session. They are seeking assistance for brief couples counseling. Complicating their relationship dynamics is the fact that they are both medical residents who are living in two different states, in high-stress fields. Reportedly, Wesley called off their wedding due to concerns about individual differences such as Patricia’s passivity. As he stated this more directly, Patricia became more submissive and withdrawn. Later on in the session, with encouragement, Patricia became gradually more communicative. Then, both began to power struggle over who possessed the superior way of interacting, which they began to morph into who was inherently superior. Despite various subtle and blatant attempts to redirect the session and help the couple take responsibility for their individual roles, their discussion escalated and Jeff’s voice was drowned out by the bickering. Spontaneously, in the midst of this, Jeff blurted out, with a faint smile, “I don’t know why you all are arguing about this. As the counselor, MY WAY of communicating is clearly the best.”
Was this an appropriate application of humor in the session? If so, was it germane to the couple’s reason for seeking therapy? If not, how did you see this as potentially destructive or ineffective?
How would you describe the target of the humor and the greater context it was being used?
Before using this intervention, what mitigating factors (e.g., interpersonal differences) or therapeutic issues (e.g., transference) would you have needed to assess in the client and therapist?
In what ways might you respond to the client’s reaction if the intervention was unsuccessful?
What other interventions might you consider in this situation – with or without the use of humor?
This couple sought therapy due to relationship problems leading to and following Wesley’s decision to post-phone the marriage. In addition to addressing the presenting communication dynamics, the long-distance nature of the relationship makes working on enhancing communication seems especially vital. The humor provides an opportunity to point out the pattern without being passive (one of Wesley’s complaints) or sounding overly critical (another dynamic) clearly being demonstrated.
The humorous response was generated to point out the tendency of the couple to respond reflexively by blaming and deflecting responsibility. Also, the response reflects the couple’s regression or “immature” behavior when relating. One worry in couple’s therapy is the risk of “taking sides”. This intervention being targeted to the situation versus an individual reduces that possibility.
Before considering this intervention, several issues may need to be a part of one’s internal dialogue. Most importantly, the social worker’s level of frustration would need to be addressed. This intervention would certainly be met with anger or a sense of being judged if this tone framed the intervention. A newer clinician may be likely to experience this, or a therapist who is feeling protective of Patricia. Anyone who is feels emotional over issues in their own relationship needs be cognizant of the risk of counter-transference.
A therapist who is feeling the need to compete with them or insecure might avoid this intervention, as it would likely be perceived as hostile. Another consideration might be Jeff’s (therapist’s) proximity to the ages of the clients. A younger therapist may be accused of being “too young” and mocking something they do not understand. Also, a therapist that could be viewed as parental may more easily feel judged – though humor makes this less likely that pointing out the problem in clinical terms again.
An unsuccessful client reaction may include silence or the couple continuing their argument. One might consider saying the same thing in a different way or louder. Also, asking the couple if they thought they were better at being stuck than the therapist is as skilled at helping them get them “unstuck.”
Other interventions that may be considered in the outset include whispering to the couple, a common technique used to de-escalate children. Also, asking the client “Wow, is this what happens at home? How does this sit with you? Are you satisfied with the results?” Doing something such as completely disengaging by reading or writing and turning away from the couple may demonstrate the effect they have on each other.
An important point to eventually illuminate would be the fact that Wesley is accusing Patricia of being overly submissive, yet efforts for her to assert her differences are met with argument. Thus, Wesley could address the need to give Patricia more opportunities to share uninterrupted. Also, working with Patricia to communicate her feelings earlier and before she feels the need to defend herself would be important.
SCENARIO TWO
Cathy recently graduated with her Master’s in Social Work and obtained a position as a medical social worker in the local county hospital’s oncology unit. Part of her job function is to perform psychosocial evaluations, triages, referrals, and short-term counseling for patients while they are hospitalized. Kathy has been asked to begin screen members for a cancer support group, which will be co-lead by one of the lead oncology nurse practitioners. Cathy met one of her first clients, John, a young man in his late 30s recently diagnosed with a rapidly spreading brain tumor. John became easily agitated and looked at her stating, “What do YOU want?!” When Cathy gently and thoroughly explained her role, he responded, “I’m not crazy, why would I need a shrink?” Cathy responded by trying to normalize his sense of frustration and shame, but again, was met with anger. “It’s my family that needs counseling; they are the ones that are freaking out over this. Why don’t they go and talk to a darn group?” When Cathy agreed to offer support to the family, John remarked, “I have already accepted that this is the end, I certainly don’t need to be reminded of that by you or anyone else.” Cathy then responded, “Well, if you aren’t interested in working in the group as a patient, how about as a leader, we could certainly use someone who is in the acceptance phase!”
Was this an appropriate application of humor in the session? If so, was it germane to the individual’s reason for seeking therapy? If not, how did you see this as potentially destructive or ineffective?
How would you describe the target of the humor and the greater context it was being used?
Before using this intervention, what mitigating factors (e.g., interpersonal differences) or therapeutic issues (e.g., transference) would you have needed to assess in the client and therapist?
In what ways might you respond to the client’s reaction if the intervention was unsuccessful?
What other interventions might you consider in this situation – with or without the use of humor?
The target of the humor appears to be John’s resistance to joining the group, to process his struggle by walking through his emotional processes with others, and ultimately to find create his own meaning in this life-altering circumstance.
The thought of using humor in this situation should be somewhat clinically intimidating. First of all, John is not choosing to seek psychotherapy. He may even resent the notion, and how this implies he is choosing to be cancerous. Secondly, John might see any use of humor as offensive, because anger seems to be his main expression. Understandably, John would likely be his anger at the cancer, the world, and his Higher Power.
Naturally, Cathy would be a target for this anger. It is presumed that she is healthy and young, and this would conceivably trigger his sense of unfairness and injustice. Perhaps John has a sense of sadness, or even guilt that he is being punished for something. Since we know little about his upbringing or other significant factors, this is especially risky.
This intervention could easily be taken as sarcasm the casual observer, and clearly it would be difficulty to imagine how John could be accepting any of what is happening at this point. From a medical standpoint, we must also have a sense of the progression of the cancer and how it may be affecting his neurological functioning.
Thus, part of the screening process, before verbally interviewing the client, would need to be consultation with the nurse as to the appropriateness of including him in group. This may have eliminated the prospect of involving John in group, the surface goal of this intervention.
Responding to this may involve acknowledging that John has a right to feel any way he needs – to give him a sense of control. Sincerely offering to involve his family may be helpful, even though he requests this in protest of his own involvement. Seeing their involvement may settle his defenses enough to connect in other ways.
Also, the existential dilemma of time might be incorporated into this situation. Clearly, time is an issue that can be captured by acknowledging their time is valuable and limited. The clinician offering to be a part of whatever decisions they make or discussions in making those decisions may be a way of respecting the reality of his situation.
Once John feels more connected with Cathy (or if), then the use of humor in this situation would be more feasible, versus having this as an icebreaker or persuasive intervention. At this point, John would be more likely to appreciate humor that is more cynical in nature, which would probably come from other cancer patients.
SCENARIO THREE
Carl is a professional counselor who serves at a lead therapist at a clinic providing brief, system-focused, family therapy. He has been working with a family for 4 sessions and feels he has a solid grasp on some of the dynamics. The family consists of Karen, 47, the mother and wife; Robert, 50, the husband and father; and Skye, 15, the daughter. The family began seeking services after Skye’s school guidance counselor recommended they do so because she was becoming more oppositional and irritable at school during the past several months. The school counselor had a difficult time contacting her parents to discuss the situation. During the session, Robert constantly berated himself for working too much and essentially being unavailable to Skye. Then, Karen would automatically come to his rescue by consoling him – explaining why he had no other choice but to work overtime to afford the lifestyle to which the family had grown accustomed. In the midst of this, Skye would become more withdrawn while rolling her eyes and letting out a noticeable sigh of annoyance. Her parents would fail to notice without Carl directly verbalizing his observations. However, even after doing this and even trying to gently inquire and speculate about Skye’s feelings, she denied any animosity or suppressed emotions, and her parents expressed little curiosity or concern about the origin of or potential for these feelings. At one point in the session, Carl made eye contact with Skye and then at her parents. He picked up his a couple of little foam balls and began to juggle them in the air while Karen and Robert continued to interact exclusively as a dyad. After a minute or so, the parents everyone stopped and began to stare at Carl. Carl stated, “I was wondering how we would get your attention.”
Was this an appropriate application of humor in the session? If so, was it germane to the family’s reason for seeking therapy? If not, how did you see this as potentially destructive or ineffective?
How would you describe the target of the humor and the greater context it was being used?
Before using this intervention, what mitigating factors (e.g., interpersonal differences) or therapeutic issues (e.g., transference) would you have needed to assess in the client and therapist?
In what ways might you respond to the client’s reaction if the intervention was unsuccessful?
What other interventions might you consider in this situation – with or without the use of humor?
Joining a family system can be a challenging endeavor for even a seasoned therapist, and often requires a playful, creative approach to avoid defensiveness or alienation of the members. In this situation, and quite often, an important distinction needs to be made between the family’s reason for seeking therapy and the reason they were referred.
Clearly, the family would likely name Skye the identified patient, where, in contrast, Carl and the referring school counselor may consider the family system to be the patient. The reasons for this are two-fold – the school counselor’s difficulty connecting with the parents and Carl’s systemic theoretical orientation play a significant part in conceptualizing the presenting issues.
Predictably, the depiction of the challenges displayed during the session appears to be consistent with the challenges the family encounters out of therapy. Thus, this makes an intervention, especially one that involves a playful approach, useful. Another approach may add to the sense of guilt Karen and Robert experience.
This intervention is a wonderful attempt to, first, interrupt the cycle of Robert’s self-deprecating and Karen’s rescuing which tends to alienate Skye, and ultimately trigger her acting out her frustration and isolation in maladaptive (i.e., oppositional behavior at school) and indirect ways (i.e., at school rather than directly to parents and through non-verbal means such as eye-rolling and sighs of annoyance).
Another benefit of this intervention is to bringing the family, including Skye to a consensus. All members would likely agree to the randomness and goofiness of beginning to juggle in the middle of a family session. This intervention would allow the family to step out of their roles and allow the therapist an opportunity for the therapist to interject feedback. This will provide the opportunity to demonstrate and broach the subject of Skye’s acting out serving an important communicative purpose.
This humor will likely be better tolerated, because, at first glance, will perhaps make the therapist more vulnerable (i.e., appearing silly and perhaps unorthodox). However, the intervention clearly targets the parent’s contradiction; wanting to help Skye but feeling too enmeshed with the other to realize why they cannot.
The parents may express frustration over the playfulness of the intervention and how it trivializes their concerns. Expressing this may provide a chance for them to unknowingly role model direct, healthy communication to the therapist. Moreover, Carl might educate the family on how more subtle non-verbal signals and pleas for support may be missed if they are unaware or too preoccupied to be looking for it.
Taking it one more step, Carl may find it useful to ask the parents and Skye to point out how they subtly communicate in general. If that is fruitful, directing the members to identify “missed opportunities” in the session to be attentive may be additionally productive. However, Carl would need to help the family identify taking responsibility versus enabling and blaming – they could easily get stuck in this process.
Of course, Carl would need to be careful of not blaming the parents, but reiterating how people communicate in various ways, sometimes through actions and signs, and sometimes through words. Connecting with the parents may involve further exploring the sense of shock and over-responsibility they felt in hearing of Skye and her difficulties; and the importance of learning to manage these feelings without losing sight of Skye’s needs.
Also, directing Skye to discuss how she “juggles” in different ways may help her gain insight into the need to be more assertive. Then, helping her do that would be crucial in the family session. Since Skye is less likely to give more than monosyllabic responses, engaging her with questions starting with “Is it possible that you are expressing yourself by..., and are uncomfortable being more direct with your parents.”
Given the family’s difficulty with directly acknowledging issues, helping them implement fun ways to communicate their concerns, even non-verbally, might be a starting point. “What can you all do to grab each others attention when it is getting tense?”
Recommending some separate sessions with the couple and Skye may be useful. This will provide an opportunity for Carl to explore the individual beliefs and fears that foster the marital enmeshment. Also, Skye will then be allowed to identify and express herself honestly without worrying about how her parents might respond. Then, Carl could work with her to brainstorm and rehearse ways to approach her parents.
SCENARIO FOUR
Jacob is a post-doctorate clinical psychologist working as a group therapist for an adolescent anger management group in an outpatient treatment center. The group is open-ended for males ages 14-17 and the presenting problem revolves around anger-related relationship problems with teachers, students, or parents, related to anger. The format is psycho-educational and therapy process with a solution-focused bent. Jacob has taken the group over after the previous long-time leader retired. A group member, Brian has been diagnosed with depression and oppositional defiant disorder. Per the previous therapist, Brian has made some progress in the group in terms of recognizing how his hostility masked his vulnerability, and using this to adopt a leadership role in the group. Brian was extremely attached to the previous therapist, and was struggling to adapt to the changes. This is evidenced by continued subtle, frustrated statements he vocalized in group comparing the previous and new therapist unfavorably. When Jacob made efforts to attend to these remarks, they were met with sarcasm which began to derail the group from focusing on their presenting problems. On one particular occasion, Jacob had the group begin to brainstorm “ways to cope with the group transition and loss”. The consensus was the group wanting a therapist that more closely resembled the previous therapist in age and style. Even if this was approved by the center, Jacob pointed out the obvious flaw in that idea, being that an older leader would also retire soon, and leave them in a similar predicament. Brian then chimed in by asking how long Jacob would be there given he was not a “real therapist” yet and the group was only his “school project.” Jacob responded by stating in a casual tone, “I will stay here as long as I need to. In fact, I will repeat the year or apply for this position after completing my dissertation. Nothing and I mean NOTHING will keep me from leaving this group!” “What about family emergencies or your own death?” the group asked. Jacob replied “I plan to reincarnate as an older, wiser, immortal therapist so you will never have to worry about a leader leaving you again!”
Was this an appropriate application of humor in the session? If so, how was it germane to the group process? If not, how did you see this as potentially destructive or ineffective?
How would you describe the target of the humor and the greater context it was being used?
Before using this intervention, what mitigating factors (e.g., interpersonal differences) or therapeutic issues (e.g., transference) would you have needed to assess in the client and therapist?
In what ways might you respond to the client’s reaction if the intervention was unsuccessful?
What other interventions might you consider in this situation – with or without the use of humor?
In this situation, working with the adolescents, during a group transition, is a uniquely challenging prospect. Developing relationships with the members, especially the leader requires a great deal of skill. Humor could be an icebreaker, but it can easily backfire if the tone and timing are not considered.
The application of humor in this vignette is problematic for several reasons. Even if the content was appropriate, there is a high probability that this will be communicated with an angry affect. Given that Jacob is likely on the defensive, this using humor is a risky proposition as it may be interpreted as sarcasm.
Being overtly sarcastic with clients or mocking is always inappropriate, given that a clinician will serve as a model for interpersonal communications. Moreover, this may also trigger angry reactions in the members. The group leader making mistakes in group can provide an opportunity for the therapist to model taking responsibility and humility. The process of the therapist being humanized in the group may serve to lower the group resistance and begin to establish trust.
If the affect was more light-hearted, there are still a few problematic issues based on the content of the intervention alone. Since the group is struggling with the loss of the previous group leader, anything that would be seen as mockery should be avoided. This entire dialogue between Jacob and the group appears to be adversarial, even in the beginning.
Perhaps the most effective part of Jacob’s intervention is when he asked the group to come together and brainstorm ways to cope with the transition. Unfortunately, Jacob would have been better served had he let the group members come to their own conclusions rather than shooting down the idea of hiring an older therapist.
Humor may have been more appropriate in this situation if several variables were different. Obviously, if the previous therapist was viewed unfavorably, or if more of a humble, mildly self-deprecating tone would have been taken by the therapist. Perhaps, asking the clients for their guidance during the transition, remarking on Brian’s progress, as reported by the previous therapist.
Other options may include having the group discuss other losses and how they relate, as well as how loss ties in to anger, and what other emotions are being covered up. As Brian is clearly affected by this, looking at how sadness, anxiety, or guilt may be interwoven may be useful.
Finally, responding to this intervention may include role modeling a more humble approach, noting that we this is new for everyone, including Jacob. Paying homage to the previous therapist might be important in the grieving; and perhaps suggesting the group develop a ceremony might be meaningful. Also, Jacob would need to enlist Brian’s (and the group’s support in the transition more directly.
As we have discussed in this course ad nauseam, there exists no substitute for sound clinical judgment that comes from experience. Many clinicians will likely find the use of this specific humor in this particular scenario to be potentially destructive, and will consider other avenues for intervention.
SCENARIO FIVE
Sally is a social worker at a Center for Women doing long-term therapy specializing in women who have been emotionally abused. She has been working with Sam, a 26 year-old, Single, Caucasian, female nearly a year using a traditional psychodynamic approach. Her reason for seeking therapy is to learn how to attract men that will treat her better. One of the ways Sam manifests her low self-esteem is through magnifying her negative attributes and discounting the positive. Unfortunately, many of Sally’s attempts to offer supportive feedback result in the client providing more and more examples of how people view her negatively. Though Sam sees herself as fragile, she adamantly rejects compliments, and even states she wonders if people do this to placate her. One day, Sally pointed out the contradiction between Sam perceiving herself as passive while assertively taking issue with her lack of trust in people. Predictably, Sam again tried to counter this intervention with describing how this situation was different because it was not “real life.” Towards the end of the session, Sally remarked, “Wow, maybe I have been going about this all wrong. If this is your understanding of submissiveness, perhaps we should be trying to help you become more submissive!”
Was this an appropriate application of humor in the session? If so, was it germane to the individual’s reason for seeking therapy? If not, how did you see this as potentially destructive or ineffective?
How would you describe the target of the humor and the greater context it was being used?
Before using this intervention, what mitigating factors (e.g., interpersonal differences) or therapeutic issues (e.g., transference) would you have needed to assess in the client and therapist?
In what ways might you respond to the client’s reaction if the intervention was unsuccessful?
What other interventions might you consider in this situation – with or without the use of humor?
As Sam is seeking guidance with how to make better relationship choices, addressing how she relates to others and how her self-defeating thought processes play a role is significant. If Sam is not confronted on this particular issue, she may continue to unknowingly reinforce the people in her life that are emotionally oppressive.
The target of the humor is Sam’s perception of herself as submissive, and ultimately her victim self-image. Ensuring the interaction and persona is the focus, rather than the client herself, is important to avoid communicating sarcasm or belittling Sam, which may easily be internalized and confirm her negativistic beliefs.
The true power of this intervention exists in the pointing out the contradiction between Sam’s sense of passivity in the world and her ability to influence change. Specifically, the therapist Sally vocalizes her redefining of the word submissive based on Sam’s behavior. To suggest the definition of a word needs to be changed takes a certain degree of confidence, and is far from the denotation of passivity.
Before considering this intervention, some factors would need to be evaluated. Sally would need to ensure a certain amount of warmth and light-hearted quality would need to be present. This comment could easily be construed as frustration and a reflexive reaction to Sam’s help-rejecting. Clearly, some previous use of humor earlier and establishment of the client’s ability to recognize and be amused by ironic statements would be important.
What might one consider an unsuccessful reaction to this attempt? Sam becoming disengaged could be an example, as this would warrant an amount of distress, while defensiveness or intellectualization would probably be expected. Especially because Sally operates from a psychodynamic perspective, she would need to be willing to return to the process and relationship focus.
Probing questions may be used to ask “I am wondering how you are taking that last comment;” followed by “What is it like to consider talking about this?” A more submissive response might be communicated as an opportunity to practice assertiveness so it becomes more natural. An assertive response may continue to reinforce Sally’s point about Sam’s overestimation of her docility.
Also, a direct parallel might be drawn for Sam – one that ties this difficulty in accepting the compliment and fact she is more assertive, as making it more difficult to connect with people who respect her. Exploring how various double-standardized stereotypes are often perceived as pushy where men are seen as direct may be useful.
Addressing any secondary gains or protective reasons for seeing herself as passive, an ultimately a victim, can be explored. Certainly the need to pathologize is easily reinforced by many in and outside of the psychiatric community. This may raise a bigger question of her identity and how Sam fits in her own life. Sam’s investment in seeing herself this way may indicate a sense of emptiness in not knowing how to relate to herself or others out of the victim role.