Posted by: counselorcarmella | May 3, 2012

Lessons From Tina

A slightly different version of this piece was published in   “Visions,” the quarterly newsletter of the American Association  for College Counseling in the summer of 2004

http://www.CollegeCounseling.org

Names  have been changed to protect privacy

 

As I proceed toward the completion of my graduate degree in counseling and my internship at a college counseling center, I have been reflecting on the various clients I’ve worked with. One of the clients that stands out is Tina.  Receiving appropriate supervision with this challenging case helped me gain much-needed skill and confidence.  The vital role of proper and supportive supervision is a lesson I’d like to share with other counseling interns.

 

Tina presented for counseling in the fall of 2003. I knew from the beginning that her case would be an excellent cross-cultural learning opportunity.  Tina was African-American and I am Caucasian.  Also, Tina believed she was probably lesbian while I am heterosexual. She was the first client of a sexual orientation other than my own that I’d worked with. I took a tape of our first session to my supervisor, Martin, to make sure I seemed comfortable discussing sexuality issues with her. He confirmed that I seemed to be conveying empathetic understanding and did not appear uneasy with the topic of Tina’s attraction towards other women.

 

Tina was in her mid20s and  moved to SC from another state to attend school. She struggled with guilt related to being raised  in a family and church that held very  conservative religious beliefs. She  was experiencing social isolation, had family and financial concerns, and struggled with chronic medication-resistant depression. After our first session, I got Tina scheduled to see our staff psychiatrist who began  monitoring her medications. I began meeting with Tina on a weekly basis and set about establishing rapport and  getting to know her better.

 

About a month into our work, Tina began matter-of-factly telling me about impulsively dangerous behaviors she’d previously engaged in, such as unprotected sex with  strangers, cutting and burning her arms, and excessive alcohol use. She also told me about numerous incidents of sexual experimentation/exploitation during her childhood. I was astounded by some of the things she disclosed, and consulted my supervisor about how to proceed. I wondered if  everything she said was the truth, if she was trying to shock me,  or if her disclosures meant she really did trust me. I knew that Tina’s case was more complicated than I’d initially thought, and wondered if I’d reached the end of my ability to help her.  I had not yet had much experience working with more seriously disturbed clients. Martin  helped me talk through  my  doubts about being “qualified” to help Tina. After reading my session notes, he  shared my concern about some of the things she’d disclosed, but assured me that I had the skill and necessary on-site resources to continue counseling Tina. I was relieved, as I very much wanted to continue working with, and learning from, her. Knowing I  had  skilled clinicians from various backgrounds  around me to consult with  at any time also helped me to feel more confident in my work with  Tina.  

 

In mid-November, Tina came in and calmly told me she’d tried to kill herself the previous week by overdosing on pills. This was the first suicide attempt I’d dealt with. Though it seemed to have been an impulsive act, I wondered if I’d missed some sign, or not done something “right.”  I also wondered why Tina hadn’t tried to contact our office for help before  taking the pills. After she’d finished telling me of the  experience, I asked her permission to call in my supervisor. With Martin’s help, it was decided that Tina did not need to be hospitalized. Instead, we helped her develop a plan for how she would spend the next few days, and what she would do if  she began feeling suicidal again. This plan included who she  could call  if she needed help (our office, a friend, 911, etc) and distraction techniques she could use to  get herself to think about  other things besides harming herself.  From observing Martin, I was able to learn more about how to  structure such sessions in the future.   Martin came in the  next week to follow up, but only stayed for part of the session. This communicated to me that Martin believed I was skilled enough to continue my work alone with Tina.

 

The rest of the semester was relatively uneventful, and we discussed things Tina would do to keep herself safe over winter break. I fervently hoped she would be okay, and was relieved when she called to set up an appointment once spring semester began. During the spring semester, Martin became my case manager, and I began working with a different supervisor, Laura. I presented a video of a recent session with  Tina to Laura as an example of my work with a client I’d been seeing over several months. Tina had begun implementing some very constructive  thinking and behavior patterns into her life, and I was hopeful that perhaps her depression was finally beginning to lift.  

 

About a month into the semester, Tina  began telling me about extremely vivid imaginary experiences of several types that she’d been having on a regular basis for years. She’d never really shared  these  details with anyone before, but remarked that she felt she could talk to me about “anything.” I was glad to hear her say that and fascinated to learn more about   what  went on in her head. These experiences were normal for Tina, and didn’t seem to distress her. but I was concerned about  the  unusual situations she described. I presented  videotapes of these discussions to  Laura. Laura was concerned enough to pull in a clinical psychologist who worked with a lot of trauma cases to watch part of the tape. The psychologist commented to me later that she thought my assessment of the situation and line of questioning and responding were   excellent, which made me feel really good about my skill level. I’d really had no idea what to do except to be curious and gain as much clarity and  information as I could.

 

Laura suggested we administer the PAI (Personality Assessment Inventory) to Tina in order to get a more complete picture of what was going on. Tina agreed,  and Laura  did the assessment. Laura and I discussed the results during supervision. She also came in during my next session with Tina to talk with her about the information presented by the assessment scoring.  I wasn’t familiar with the PAI until that point, and found Laura’s guidance in using it very  enlightening and helpful. We came to believe that Tina was experiencing  these “daydream realities” as a response  to past trauma, not psychosis. We deemed them as just a different way of coping, and something to keep a watch on. Having Laura’s  help in drawing conclusions about what was probably going on with Tina at this point was extremely important, as I was very concerned that Tina was experiencing a more major mental illness like schizoaffective disorder or some other delusional  or psychotic disorder.

 

Throughout the remainder of the spring semester, Tina continued to experience varying levels of depression, and still struggled with the spirituality and sexuality issues she came to counseling with initially. She was also concerned about career choices. I believe she made progress with these concerns, though. She implemented a number of  constructive cognitive and behavioral strategies for helping herself. The last time she felt suicidal, Tina obtained the means to make the attempt, but then decided not to go through with it. I think  the solid relationship we had and my acceptance of  Tina for who she was was also helpful. Tina plans to move during the next few months, and is hopeful that a change of  environment will be good for her.  Our final few sessions focused on her more hopeful future and the meaning she has made of what has been a difficult few months. She plans to continue her use of various mental health resources in the community.

 

I value Tina greatly as a person with tremendous strengths and resilience, and am so glad I had the opportunity to work with her. If I had known in the beginning how complex her case would become, I probably would have referred  Tina to a more experienced staff member. I’m glad I didn’t know, though, and that my supervisors  had enough faith in me not to force a referral. Tina, and the variety of resources available in working with her, proved invaluable to my learning, and to my confidence level as a developing therapist. I know I can handle a variety of difficult counseling situations appropriately partly due to the array of issues I dealt with in Tina’s case and the supervision I had related to them. We learn through experience and working with Tina was an experience I’m not likely to forget.

 

 

** Looking back on this case with the benefit of a few year’s experience, I feel it was very likely that Tina was experiencing borderline personality disorder.  I believe participating in a Dialectical Behavior Therapy program would have been very helpful for her.  I hope she is doing well, wherever she is.  Tina was very intelligent and had a lot of  artistic talents.  I hope she has been able to continue to use those as part of her healing journey.

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