What counselor responses would you change or revise and why in the session 1 dialogue?

Crisis Intervention with a Substance Abuse Client

Francis is a 39-year-old married man who recently learned that his wife of 10 years is filing for divorce because of his marijuana and cocaine addiction. He also learned of an ongoing affair she is having with his best friend. Francis has been distraught for several days upon hearing this news and is contemplating suicide. At his mother’s insistence, Francis begrudgingly decides to attend the initial appointment she made for him with a counselor who specializes in substance abuse and crisis issues at the local mental health agency. Francis is aware that his drug use was causing some problems at home and has tried several times to stop, but he has been unable to maintain abstinence for more than a day. He reported that he was in counseling 2 years ago when his wife threatened to leave him but was not motivated to change and dropped out after a couple of sessions. He also did not feel the counselor was listening to him and was instead telling him what to do. He acknowledges his drug use has caused some problems and is really upset over his wife’s affair with his best friend. He is coming to the realization that it is too late to save his marriage. He states to the counselor that he has no reason to live. Let’s examine how the counselor may structure the first six sessions.

Session 1:

The counselor must undertake several tasks simultaneously. Understanding what was helpful and not helpful from the client’s previous counseling experience can provide valuable information as to how the client views counseling, approaches that should be avoided or enhanced, a sense of motivation, and ways to conceptualize how best to establish a working alliance. Establishing a working alliance is essential given the client’s fragile emotional state. While the counselor is working to establish rapport and create an environment where the client can feel supported, effort must be directed toward the client’s message of desperation and suicide ideation. The counselor must assess the severity of the client’s statement around self-harm. During this process, the counselor must assess the level of intent and determine both the subjective (client statements) and objective (specific concrete behaviors) messages. Using direct language (direct questions versus reflective responses) is necessary to evaluate intent, means to carry out the intent, and a clearly developed plan. Conveying this information in an empathic manner creates a sense of care and concern that increases the likelihood the client will come back next session. Let’s look at the counselor–client dialogue related to examining intent.

Counselor: Francis, I appreciate your willingness to seek help and for being open with me. I want to ask you a few questions to help me better understand your emotional state.

Francis: OK.

Counselor: Tell me about what you mean by not wanting to live anymore.

Francis: My world has fallen apart. My wife has been upset about my drug use for some time, and I think it drove her to having an affair. I’m really torn up by this and don’t see any reason for living. I really screwed up.

Counselor: You mentioned or alluded to a couple times today that you don’t want to live. Before we talk about what is going on right now for you, let’s discuss any previous suicidal thoughts or attempts. Have you made any suicide attempts previously?

Francis: No, never, but I’ve thought about it from time to time, especially after my wife and I got into fights about my drug use.

Counselor: At that time, did you have a plan to hurt yourself and, if you did, did you have the means to carry it out? (Give examples of methods.)

Francis: No, I didn’t have a plan. It was just thoughts running around my head that I couldn’t let go of. I got really scared of my thoughts because I didn’t feel I had any reason to live. I felt that I’m no good to her or anyone. I felt overwhelmed and the pain was unbearable.

Counselor: You felt so distraught and worthless because nothing seemed to matter anymore. The only solution in your mind was to commit suicide. Describe your intention to hurt yourself at that point.

Francis: I thought a lot in those moments about killing myself, but I didn’t because I would have hurt more knowing my children and my mom would have to live with this.

Counselor: Francis, you were aware of the painful outcomes killing yourself would have on loved ones. Help me understand more about your state of mind during that time. Did you think of or have a plan in place and if so did you have a means to carry out that plan?

Francis: No plan. I just wanted the pain to go away. I started to use more drugs to numb out.

Counselor: Did you plan to use more drugs with the hope of killing yourself? (Exploring drug use as a possible means to carry out suicide is important to assess as it can be easily overlooked with the focus on more acute means of lethality.)

Francis: No. I never planned or intended to overdose or use drugs to kill myself. Only to take away the pain.

Counselor: So you had no specific plan or means?

Francis: That’s right. I guess I chickened out.

Counselor: Choosing to live when you were facing incredible pain takes a lot of courage and strength. (The counselor continues to use empathy to build support, rapport, and trust.)

Francis: I guess, but I’m not feeling a lot of courage right now.

Counselor: Describe your current thoughts about wanting to kill yourself. (The counselor may use a 1 to 10 scale to help assess, with 1 being no intent, plan, or means to kill myself and 10 being a definite plan and means to kill myself.)

Francis: Kind of like what we talked about before. Feeling really overwhelmed. Maybe a 3 or 4.

Counselor: So a 3 or 4 would indicate feeling overwhelmed like what you felt before or is it more than before?

Francis: Pretty much the same.

Counselor: Thank you for helping me to understand. Francis, given these recent painful experiences, do you have a plan or means to kill yourself right now?

Francis: No. I just feel really awful. I just wish the pain would go away.

Counselor: The pain feels really unbearable, so much so that you think that the only way to reconcile it is by not existing anymore. (If the client mentioned a plan and intent, the counselor would explore in detail the plan and means. The counselor would ask about specific sources to carry out suicide and continue to examine multiple methods until the client states that no other methods have been considered.)

Francis: Yes. (Francis cries for several minutes.) And I don’t know what to do next ‘cause nothing has worked out and my wife is leaving and screwing around with my best friend because of my drug use.

Counselor: It sounds like you don’t want to die, you just want your life to make sense. Right now you are uncertain what direction to go in to alleviate the pain. You know that drugs have not helped the situation, but they have been the only thing that has helped to numb the pain.

Francis: Exactly! I know this is no way to live my life. I’m tired of feeling this way, but it’s the only thing I know that works and I’m not sure I want to let go of using drugs at this point. (The client’s affect brightens a little and seems a little hopeful that he is being listened to. Something he complained his wife never did.)

Counselor: It sounds like the relationship with drugs is causing a lot of pain and problems, but you’re not ready to let it go. Maybe we can work together to examine this relationship and the costs/ benefits of using versus not using.

Francis: It’s something I’ve been thinking about. I’ve been trying to figure out why I keep doing this when it causes so many other problems, but I need it and I’m not sure I can give it up right now ‘cause it hurts too much when I don’t use drugs.

Counselor: Let’s not focus on all or nothing options related to use. Would you instead be open to examining your use and understanding what purpose it’s serving for you?

Francis: I’d be open to talking about this.

Counselor: To help start that conversation, I have some materials that others have found helpful as they attempted to understand similar issues you’ve been facing. Would you be interested in looking these over between now and our next session?

Francis: Yes, I’d be interested.

The counselor established that there was no chronic suicidality or previous attempts. Client responses indicate mild risk and the counselor should evaluate and monitor risk on an ongoing basis. The client has difficulty when facing challenging situations, feels overwhelmed, often uses substances impulsively to manage emotional instability, and has a history of fleeting thoughts of suicide but no established intent, plan, or means. During the remainder of the session, the counselor will assess the client’s drug use and motivation to change. The counselor is still concerned about the client’s strained emotional state and will work to establish a plan in the event that the client’s condition worsens before the next session. The counselor may consider using the commitment to treatment statement (CTS), an agreement to commit to the treatment process and to living, and a crisis response plan that outlines specific behaviors the client will engage in if the crisis escalates (see Rudd, 2006).

The counselor and client also work together to examine a realistic plan for substance use. It is evident the client is in the contemplative stage, and the counselor wants to continue to enhance client understanding and awareness. The counselor also commits time in session to discussing the marital issues and explores the dynamics that have triggered this recent crisis situation. The client is feeling better at the end of the session and they agree to meet again in 4 days. At the end of this session the counselor must thoroughly document the session and provide specific content related to the suicidal ideation, established patterns, and current condition. The use of direct client quotes strengthens the record.

Session 2:

The counselor continues to build rapport and establish the therapeutic working alliance using basic reflective skills and advanced skills such as clarification and immediacy as needed while helping the client color in the details related to the presenting problem, including the implications of the affair. In this session, the counselor assesses the client’s emotional state and explores behaviors and activity during the past several days and evaluates whether different interventions are necessary. Motivational enhancement approaches continue to serve as a building block for exploration of the client’s substance use and assist in shifting the client’s ambivalence toward change. The exploration and implementation of treatment options will align with the client’s stage of change. Assessing cultural factors and their role in understanding a client’s motivation level is important during the second session. Also, the counselor discusses the bibliotherapy assignment and specific reactions, thoughts, insights, and how the client has integrated this information and any newly acquired knowledge into his situation. The counselor and client discuss additional options, including continued bibliotherapy options, and the possibility of listing advantages and disadvantages of current substance use for the next session. At the end of the session, the counselor and client both summarize salient issues, and the counselor reminds the client of the behavioral plan in the event the crisis reemerges.

Sessions 3 to 6:

Evidence of a stronger therapeutic alliance is emerging with ease of rapport and signs that the client is trusting the counselor. The exploration of presenting problems continues. The counselor notices that the client has chosen options to help explore ambivalence, including a handwritten list of the advantages and disadvantages of drug use. The client reported that he knew his substance use was a problem but did not understand the magnitude until he made this list. He reported that he wants to make changes and wants to end this relationship with drugs. He also realized how much he alienated his wife and, while still very hurt and upset over her affair, understands how his drug use contributed to this process. He reported that he wants to change but does not know where to begin. He also reported that he has not used drugs for the past 12 hours and has been feeling a little rough, but indicated he would like to be drug-free in the next month.

The client’s attitude has shifted from the first session, and his behaviors indicate that he is preparing to move toward making a change. The counselor recognizes this shift and works with the client to develop a plan to change and specific treatment options that align with the preparation. During this stage, the client’s motivation aligns with specific behavioral approaches and the opportunity for the counselor to use other advanced skills such as challenging, advanced empathy, and immediacy. During these sessions, working with the client to establish a support system will be critical.

At this point, the counselor would have a discussion about various types of supports and assess the client’s willingness to explore each. It is important that the counselor be knowledgeable of different support options and help the client navigate this process. For example, integrating 12-step support groups is quite common, yet many counselors may not take the time to process the client’s apprehensions or fears. Explaining what 12-step groups are about, the types of meetings available, expectations, and what a typical meeting entails can do much to allay client fears. The counselor may suggest to Francis that to help ease into this process, it may be beneficial to see whether a friend would be willing to accompany him the first time. Support is an essential step in enhancing motivation and creating an alternative to relying on drugs as a means of coping.

Discussion Questions

1. What other issues warrant consideration in this case?

2. What other considerations would you integrate into the session 1 dialogue?

3. What counselor responses would you change or revise and why in the session 1 dialogue?

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