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Sandra, 28, has been referred to counselling by her GP due to recent mood swings, where she is often tearful and upset.

Sandra is a solicitor. Two months ago, she took a new job in a large law firm, after working in a small suburban law firm for five years.

Sandra has been dating Steven since high school, who she describes as a ‘warm and wonderful person’. They live together, but are not married, and the couple are wondering about the right time to get married and have children. This has been an area of disagreement between Sandra and Steven, and has led to a number of heated arguments.

Sandra describes herself as fairly conservative and not a risk-taker, and says that sometimes she can’t believe she has accepted a job in such a large company. She is not sure about the direction she wants to go in life, and is not sure the position is right for her.

Sandra says sometimes she feels happy and reasonably good about herself, but these good feelings frequently give way to significant self-doubt and feelings of hopelessness. She often feels “not good enough” and “not worthy”. She has experienced these feelings intermittently since adolescence, but feels they are more intense and more frequent since moving to her current position. She commented: “I’m not the person I thought I would turn out to be” and “I’m disappointed in myself.”

Sandra reports being able to “keep it together” at work, and that her work is not suffering at this stage, although she worries about whether she will be able to continue doing this. She has become more restless and irritable with people, especially in social situations, which she describes as ‘excruciating and pointless’.

Sandra is the eldest of three children, and noted that she felt her father, who is a barrister, placed higher expectations on her than her younger siblings. She described her mother as ‘well-meaning, but not helpful” when Sandra wanted emotional support.

  • What are the major issues faced by Sandra?
  • What else do you need to know about Sandra’s life?

  • How would you work with Sandra, choosing two of the approaches covered in lectures (cognitive-behavioural therapy, acceptance and commitment therapy and solution-focused brief therapy)?

Consider the following questions:

o What issues might be prioritised, how you would establish this? o Who might be included in the counselling?

o  What kinds of strategies / interventions might you use?

o  What would tell you if your approach / strategies were being effective?

Issues faced by Sandra

Sandra has been suffering from mood swings and frequently found herself to be upset and been tearful sometimes. By profession she is a solicitor and she has been working in a small law firm in suburban for five years and she has taken a new job in a large law firm two months ago. Even if she is not facing much issue within her work place, she is not being able to cope up with the entire work situation. She is not suffering from any work problem right now, yet she herself feels to be incapable of giving up to the mark performance. Till now she has been capable of managing things at her work place, yet she seems to be too much stressed regarding her work. As she has not worked in a large firm before, she continuously worries about her performance in the work place. Even she is also concerned regarding the fact that whether she will be able to continue working in the firm as she is scared that she is going to have a terrible performance due her lack of experience in working in such big law firms. She is also having relationship troubles with her steady boyfriend and her live- in partner, Steven. Even if her boyfriend has been a supportive towards her, they are having heated conversation regarding their marriage and children. The couple has been wondering regarding the right timing for their marriage and having children for quite some time. They have a continuous disagreement regarding their time of marriage. Therefore all these major issues in her work and relationship have made Sandra upset and she has been having depressing thoughts.

Sandra’s relationship with her boyfriend is not clear form the case study. The case study has depicted that she is having issues with her boyfriend as they are not being able to come to a common solution regarding their marriage and having children. However it is not clear what exactly Sandra thinks about the entire situation. One cannot understand whether she is more eager to get married and have children or not. The counselor needs to know whether she is interested in having a family right now before taking her case. In addition to that, the counselor would also want to know whether she is facing any other issues within her work place. As she has joined a large company for the first time and she is not much experienced in working in such a large firm, she may face bullying, mistreatment or harassment within the work place. Therefore the counselor would want to know more regarding her work place situation. It is very much possible that she is not being able to cope up in the new company due to non-cooperative colleagues. Therefore the counselor would require knowing these few information before dealing with Sandra’s case study.

While dealing with Sandra, the counselor would use two approaches, acceptance and commitment therapy and solution-focused brief therapy. The first approach acceptance and commitment therapy deals with two principle message that the theory gives accepting the situation that is out of personal control of an individual and committing to the actions that will enrich and improve the individual’s life, whereas the former theory is a goal oriented and solution based collaborative approach.

Prioritizing the issues and determining the focus

The Acceptance and commitment therapy primarily teaches the individual the mindfulness skills that help them in living and behaving in different ways that are consistent with their personal values, therefore helps developing a psychological flexibility (Baer, 2015). There are few core procedures of the therapy that helps reaching the main goal of it. It helps in developing the creative hopelessness that tends to indicate to the previous attempts of resolving the difficult situation in lives. In addition to that this therapy also helps the individual to accept the emotional experience of him or herself. This therapy will be utilized for Sandra as it will boost her motivational level and it will also help her in accepting the present situation and focus on finding solutions to it (McCracken & Vowles, 2014). This therapy also helps the individuals to choose the valuable life decisions in a way that will define the most important thing in the individual’s life. This also helps the individual in referring to their commitments in life so that they can make changes and engage in behaviors that indicate to the most valued direction of life. Therefore this therapy can be very much helpful for Sandra in deciding her priorities in life and finding the motivation to work despite the difficulties in her new law firm.

The Solution focused brief therapy is the approach that focuses on building the solutions than solving the problems. This therapy tends to explore the present resources and focuses on the future hopes than the current issues and previous root causes for the problems (Pichot & Dolan, 2014). Through this therapy the counselor will focus on Sandra’s future career graph after working in the large law firm, than focusing on the past and present issues and problems. Therefore this will boost the motivational level of Sandra to a great extent.

In this case, I would prioritize the Sandra’s work issue more as this seems to be more prevalent from the case study. Sandra seems to be more depressed due to her work issues, yet she did not mention any specific issue in the case study at first. From her case study it seems that she has encountered a huge pressure of being very much successful from her family as her dad is a renowned barrister and she has admitted that her dad puts more importance and places high expectations from her as she is the elder child amongst the three. She has been working in a suburban firm for five long years, but she feels scared and fears to be performing low at her work place, therefore she thinks she will not be able to survive in the large company. Therefore I feel in her case it is more important to deal with her office issues as she might be facing serious issues there. A young employee who is joining a large firm for the first time can face several issues such as work place bullying or mistreatment by the senior employees. She might be facing such issues which is making her question her own quality of work. Therefore Sandra’s work place issues should be prioritized first.

Counseling Strategies and Interventions - Acceptance and commitment therapy

Sandra’s boyfriend and live- in partner Steven may be included in the counseling. It has been reported that both of them are having relationship issues as they cannot decide the right time to get married and have children. Even though it is not clear from the case study that who between the partners is least interested to get married and take the responsibility of a family at this moment. Therefore the counselor would consult him to get a more certain view of her life. They have been together since high school; therefore they seem to spend a long time together. Furthermore it is necessary to consult her boyfriend at the first place.

There can be two kinds of interventions for Sandra. There will be a separate intervention for her relationship and her work issues. It is evident from her case study she lacks motivation and therefore she is scared for her forthcoming performance within the work place. Lack of motivation in the work place can cause depression for most of the corporate employees. The main issue with it is that while the motivation is not present the employee does not feel to put more effort to reach the goals. They find surviving within the organization to be very much difficult and tend to get demoralized every now and then.

For the work issues with Sandra there can be interventions such as:

  • Cognitive restructuring– This method has been used for several patients who are suffering from depression caused by low motivation. This method is related to changing the thought process of the individual resulting into aforementioned cycle which leads to the change in behavioral patterns. These specific changes result increasing their accomplishments and motivation. With the help of the change in the behavioral patterns and the thinking processes it may be able to keep Sandra get on the track with her goals in life within a short period of time.
  • Behavioral chain analysis– This is an intervention tool that can assess the factors contributing to the difficult behavior, therefore focus on those behaviors with the effective interventions. Limiting and gradually removing the impacts of such behaviors, Sandra may be able to make effective changes in her life which may seem to be very difficult for her at the present time.
  • Contingency management procedures– The contingency management procedure indicate that human beings tend to do whatever has an immediate reinforcing nature and tend to avoid the ones which have an immediate negative effect, regardless of the forthcoming consequences. This intervention for motivation planning may help Sandra in shifting her balance of the long term consequences of the behavior, therefore the desired behavior tend to become more strengthened and easier for taking care of.
  • Anti-procrastination training– This intervention utilizes the combination of contingency management and few other techniques for stopping the procrastination of the individuals. Waiting for something positive to motivate the individual is also a type of procrastination; therefore it may be a cause of Sandra’s depression. Therefore his intervention may help Sandra in decreasing her depression.
  • Systematic exposure– This intervention will work on focusing on the evading of the situations the individuals tend to fear and believe that these situations would turn in a negative and bad way if they are assumed. In this case Sandra is avoiding her work place situations as she had fears to be neglected and does not want to be proved as a wrong investment for the management. Therefore exposing to such situations would help increasing the motivational level of the individual that have been depressing till date.
  • Mindfulness training– This intervention is a skill that have been reduced in contacting the present mood therefore the individual does not catch up with the worries and thing process. Therefore it can be expected that Sandra cam be engaged in skilled behavior rather than feeling depressed.

These intervention tools may be helpful for Sandra in dealing with her present situation at the work place.

In dealing with Sandra the counselor will also focus on adapting the intervention that focus on solving the relationship issues at the same time. The interventions for this purpose will be

  • Gottman Method- This method of counseling involves drawing the love maps of the other partner and gains knowledge regarding the psychological world of the other partner. Therefore this method helps in managing the conflicts than the conflict resolution.
  • Emotionally focused couple therapy- This intervention is a short term approach with the main focus on expanding and recognizing the primary emotional responses. This tends to secure the bond between both the partners and creates more beneficiary interactions.
  • Analyzing the communication way– The quite common basis of most of the relationship issues are the inability of communicating in a healthy way. Communication is the most significant tool that tends to bind two people into a relationship. Therefore the counselor will ensure that both the partners, Sandra and Steven talk to each other in a healthy way and come to a common decision regarding their marriage and family.

If the counselor finds a positive change in her behavior, it will indicate that the approaches are working for Sandra. There can also be several other signs that may indicate that the strategies and the approaches that are being used for Sandra’s treatment are doing it work in a positive way, such as dealing with other situations in life in a positive way, looking at life in a more optimistic method. Therefore the counselor will know the approaches and strategies are working in a right way.

References

Baer, R. A. (Ed.). (2015). Mindfulness-based treatment approaches: Clinician's guide to evidence base and applications. Academic Press.

Bond, C., Woods, K., Humphrey, N., Symes, W., & Green, L. (2013). Practitioner review: The effectiveness of solution focused brief therapy with children and families: A systematic and critical evaluation of the literature from 1990–2010. Journal of Child Psychology and Psychiatry, 54(7), 707-723.

Bricker, J. B., Mull, K. E., Kientz, J. A., Vilardaga, R., Mercer, L. D., Akioka, K. J., & Heffner, J. L. (2014). Randomized, controlled pilot trial of a smartphone app for smoking cessation using acceptance and commitment therapy. Drug and alcohol dependence, 143, 87-94.

Craske, M. G., Niles, A. N., Burklund, L. J., Wolitzky-Taylor, K. B., Vilardaga, J. C. P., Arch, J. J., ... & Lieberman, M. D. (2014). Randomized controlled trial of cognitive behavioral therapy and acceptance and commitment therapy for social phobia: outcomes and moderators. Journal of consulting and clinical psychology, 82(6), 1034.

Creswell, C., Violato, M., Fairbanks, H., White, E., Parkinson, M., Abitabile, G., ... & Cooper, P. J. (2017). Clinical outcomes and cost-effectiveness of brief guided parent-delivered cognitive behavioural therapy and solution-focused brief therapy for treatment of childhood anxiety disorders: a randomised controlled trial. The Lancet Psychiatry.

Gingerich, W. J., & Peterson, L. T. (2013). Effectiveness of Solution-Focused Brief Therapy A Systematic Qualitative Review of Controlled Outcome Studies. Research on Social Work Practice, 23(3), 266-283.

Johnson, E. T., Huck, G., Brooks, J., Moser, E., Blake, J., & Chan, F. (2015). Solution-Focused Brief Therapy. Counseling Theories and Techniques for Rehabilitation and Mental Health Professionals, 48.

Korman, H., Bavelas, J. B., & De Jong, P. (2013). Microanalysis of formulations in solution-focused brief therapy, cognitive behavioral therapy, and motivational interviewing. Journal of systemic Therapies, 32(3), 31-45.

Lappalainen, P., Granlund, A., Siltanen, S., Ahonen, S., Vitikainen, M., Tolvanen, A., & Lappalainen, R. (2014). ACT Internet-based vs face-to-face? A randomized controlled trial of two ways to deliver Acceptance and Commitment Therapy for depressive symptoms: An 18-month follow-up. Behaviour research and therapy, 61, 43-54.

Macdonald, A., Wilson, L., & Lloyd, H. F. (2016). Solution-focused brief therapy. In Psychological therapies and people who have intellectual disabilities. The British Psychological Society.

McCracken, L. M., & Vowles, K. E. (2014). Acceptance and commitment therapy and mindfulness for chronic pain: Model, process, and progress. American Psychologist, 69(2), 178.

McCracken, L. M., Sato, A., & Taylor, G. J. (2013). A trial of a brief group-based form of acceptance and commitment therapy (ACT) for chronic pain in general practice: pilot outcome and process results. The Journal of Pain, 14(11), 1398-1406.

Pichot, T., & Dolan, Y. M. (2014). Solution-focused brief therapy: Its effective use in agency settings. Routledge.

Trompetter, H. R., Schreurs, K. M., Heuts, P. H., & Vollenbroek-Hutten, M. M. (2014). The systematic implementation of Acceptance & Commitment Therapy (ACT) in Dutch multidisciplinary chronic pain rehabilitation. Patient education and counseling, 96(2), 249-255.

Tyrberg, M. J., Carlbring, P., & Lundgren, T. (2017). Brief acceptance and commitment therapy for psychotic inpatients: A randomized controlled feasibility trial in Sweden. Nordic Psychology, 69(2), 110-125.

Zhou, J., Luo, Y., Chen, Q., & Liang, Y. (2016). Cult Members three-low-and-one-high Symptoms and Theirs Solution-focused Brief Psychological Counseling. International Journal of Psychology and Counselling, 8(8), 96-101.

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