Live Supervision via Videoconference and Chat: Case Study
Scenario: Counselor is working with client who has a history of substance abuse with alcohol. Client presents with a recent relapse after having three successful months of sobriety. Counselor seems to have an agenda of focusing on the positives of his sobriety and not wanting to stay with client’s emotional pain and sense of shame/guilt over relapse. This real-time supervision and communication could be done via computer screen with text chat or verbally through an earpiece to the counselor while the session was going on.
(C): So tell me about the positive things you learned from your period of sobriety.
(Clt): Well I learned how much hurt I can cause someone when I drink. I truly love my family and my wife, but I simply couldn’t take it anymore.
(C): So it seems as if you can only focus on what went wrong and not on how well you did in your sobriety.
(Clt): I know I had some good sober time, but this relapse really threw me for a loop.
(C): Still let’s see if you can identify what you did right verses what you did wrong.
(Clt): (client is noticeably uncomfortable and shifts back and forth in his chair) I guess I don’t feel like it matters about my three months sober.
(Sup via chat): He needs to feel & experience his regret, shame & guilt before being able to see this all in a positive light.
(Sup via chat): Ask him about “really threw me for a loop”.
(C): I can see that this relapse really hit you hard, tell me about how you felt afterwards.
(Clt): Like shit, like a piece of shit. I let my family down, I lost the trust of my partner, and my belief in myself and my ability to stay sober was shattered.
(Sup via chat): Nicely done… now stay with the emotion and reflect his despair in a quiet tone.
(C): The pain is overwhelming.
(Clt): (in hushed acknowledgment) Yeah yeah (tears form, voice chokes)
(Sup via chat): Wait, see if anything more comes up, then softly say “stay with pain”, “just be with sadness”.
(C): “There’s lots of pain , take a minute and just be with the sadness” (therapist voice and intonation is sensitive and soft).
(Clt) : (sadness overwhelms client and emotions break through with sobbing)
(Sup via chat): Don’t interrupt or it will bring him into his head. Honor the experience by your silence or “that’s it, just let it out” and then stay silent while he cries.
(C) : (counselor leans in and speaks slowly and softly with client) That’s it, let it out.
(Clt): (client sobbing deepens and he cries out) I never wanted to hurt my family again.
(Sup via chat): Softly say “I know you didn’t” and then remain silent.
(C): (leans in and supportively) I know you didn’t.
(Clt): (he continues to cry and gradually comes to a place where he stops, and he speaks very softly, almost imperceptibly) I really didn’t and yet I did.
(Sup via chat): Very nicely done, don’t ask any questions yet, hold the silence.
(C): (remains silent)
(Clt): (after crying some more, he pauses for a minute)
(Sup via chat): Now let him come up for air and gradually reorient to the here and now.
(C): (does good job of staying silent while ‘being present’)
(Sup via chat): When you sense he is ready say “say more” then let him fill the space.
(C): (waits for a minute while client continues to re-orient and then sensitively and quietly speaks) Say more.
(Clt): (continues by talking about the pain of breaking his sobriety vow to his family and how much he has broken their dreams and dashed their hopes over the years, how much he wanted and wants to stay sober to prove to them that he can do this and loves them deeply)
This is the end of the scenario. From here, during rest of the session, the supervisor could then work with therapist on helping client to integrate the emotions and then and only then to reframe the relapse into more hopeful and positive terms. This case would be rich in supervisory material (both in the moment and post session) as therapist is learning in real time how to address painful emotions and honor their role as a necessary step in moving through a relapse successfully and then how to weave in appropriate strength-based material regarding what client learned from his successful period of sobriety when timing is right. Also to talk with therapist and ask him to look at his own possible counter-transference issues regarding sitting with client in pain. Can also process why the therapist had a seeming blind spot regarding necessity to process the underlying regrets , shame, and guilt before looking at what client had learned during his sobriety time. Can explore what cues (verbal and physical) that client was sending regarding not wanting to go where the therapist was initially directing and how the therapist in the future can better read those cues and adjust to where client is at. Good discussion can occur regarding MI and importance of “meeting the client where he is at” verses going with a preconceived agenda.