Integration of Theory to Practice-Case Study

Integration of Theory to Practice-Case Study

Tara Emery

Social Work Department, University of Calgary

SOWK 662 S08 Integrative Seminar

Lateef Habibi

December 1, 2023

Introduction

              In consideration of this assignment, I asked my client Sam (whose name has been changed) for consent to present her story. I met Sam when her mental health was stable and recently watched her deteriorate unexpectedly. Sam had approached me for counselling support after joining our virtual primary care clinic in the summertime. She explained that she had previous diagnosis of Acute Stress Disorder. She has had counselling supports on and off in the past but nothing consistent. Her family has had a significant history of mental health struggles. Her Mom who struggles with anxiety had also had a recent cancer scare and a pancreatic cyst removed. Her Brother has been struggling with anxiety and addictions he has overdosed a few times being revived by his mother. Her mom is a care provider for her brother which has caused “a lot of related stress” since she is also struggling with her own health. Sam’s Dad has struggled with alcohol addiction, he is now “functional” but there is a lot of related “sadness” for Sam. She described being a victim to her dad’s alcohol use, and abusive behaviour. Sam has been attending school at University of Victoria and now “UBC” for psychology and is interested in becoming a counsellor. 

Case description

              Sam identified herself as the most “normal” or well person in her family. She is 20 years old but presents as slightly older. She has strong self-care practices, enjoying a clean space and keeping good hygiene. She keeps a regular routine, has good sleep hygiene, loves clothes, drawing, and yoga. Despite the struggles in her family, she feels very close and loved by them, particularly her mom. Her mom was described as her best friend and a “strong, nurturing, soft, warm presence”. She has admired the emotional work her mom has engaged in seeing her transform from being passive to much more assertive. Her parents separated when Sam was 7 yrs. old. Currently she is living in Vancouver, Sam is “pretty isolated socially” she has a 10-year older boyfriend who is an engineer. Sam said she has always felt much older than her age and has always dated older men. She does not feel close with her boyfriend, she is unsure why but wishes to end the relationship but hasn’t out of fear of hurting him. We spoke about attachment styles and Sam identified as feeling she has an anxious style. Feeling passive and anxious around men and finding herself looking for validation and overly concerned with their needs. She prefers to keep herself at a emotional distance in her relationships.

              I chose Sam for my case study as she recently started to experience a mental health crisis and I felt she would benefit from additional supportive perspectives of my professors and peers. I have also felt curious that her current struggles come from her childhood trauma and attachment wounds. I am interested to explore how a trauma informed attachment counselling lens could benefit her. Additionally, I feel a lot of compassion for Sam as she has put in an enormous effort into her wellbeing, seeking out counselling, practicing self-care and studying psychology. When Sam described her childhood, I could feel the heavy burden she carried in being the responsible child, caregiving for her family which made me want to support her. Lastly, I think Sam’s struggles speak to gender expectations such as pleasing, perfectionism and caregiving and the pressures that many young females experience (not that men cannot experience this too).

               Sam’s case is relevant to social work in how it speaks to the challenge and complexity of developmental trauma for individuals who struggle despite excellent insight and good self-care practices. I feel it is important for social workers to understand trauma informed counselling practices to better work with individuals like Sam.

Case Analysis

Questions that I took into consideration when meeting with Sam were;

1. What were her strengths and current self-care practices?
2. What survival strategies did she utilize to survive the chaos of her childhood?
3. When has she felt loved, supported, and witnessed by others?
4. How does she see herself, what is her inner dialogue?
5. What are her fears and what might be preventing her from building closer relationships (with herself included)?

            Primarily my focus in this case drew from trauma informed practice and attachment theory. Dianne Poole Heller, a favourite attachment therapist describes how attachment wounds, especially those from our childhood, can have lasting impacts on our mental wellness and the health of our relationships. Fortunately, attachment healing is possible and common in adulthood. Having a relationship with a securely attached individual, including a therapist, helps create this foundation for healing (Heller, 2013). I felt this attachment approach would be helpful with Sam as externally she was doing well, she had good financial support from her father, she was doing well in school, she was well respected and loved by the people in her life. However, Sam described how all this external support and past success made her feel even worse when she was struggling, she would think of the people who have no support and are able to deal with all kinds of stress, why couldn’t she?  She couldn’t understand why a small amount of stress seemed to overwhelm her and completely disrupt her sleep. However, what I noticed was a young woman who was constantly comparing herself to others, expecting perfection and terrified of failure. The support that her family offered (financial and emotional) saying she could take time off school was not helpful because Sam could not conceive accepting the support. I could also see how in her childhood there wasn’t capacity in her family for her to act like a child and make mistakes so how could she see this as possible in adulthood? When Sam and I explored this sense of responsibility she carried she remembered feeling jealous of her brother when he would have a temper tantrum thinking if only, she could do that (and then she felt guilty because she knows her brother has suffered so deeply).  It seemed that Sam’s attachment blueprint left her feeling she was mostly alone in the world and that she could support others, but she couldn’t rely on or easily accept support herself. 

When planning for Sam’s interventions I wanted to keep in mind that early inferences about self and others, referred to as “relational schemas,” are encoded preverbally. These childhood memories are non-verbal, and they do not have a sense of time; they are triggered by environmental stimuli and are referred to as implicit memories (Brier et al., 2014, p. 202). A talk therapy style might not be effective for working with these early childhood memories. As the solution can require finding ways to help people alter the inner sensory landscape of their bodies (Bell, 2015). My hope was that if I utilized an attachment-focused mindfulness practice, we could increase body-based awareness allowing us to build increasing awareness of the secure attachment system. Posing questions like, “when your mom supported you, how did you feel, what sensations did you notice in your body?” strengthening this internal system of support. 

Interventions

              Following the assessment phase (2 meetings summarized above) Sam and I engaged in monthly sessions sometimes meeting more often when she began to experience insomnia. This is a summary of our sessions.

1. Sam felt unsure, where to “put it all” regarding her sad emotions toward her mom. Somatically she described a pit in her stomach, and noticed increased worry for her mom, and increased anxiety (assuming the worst cases for her family). Sam said that she was aware that she has learned to suppress her emotions. We noticed how this was likely a coping style from her childhood. We explored how her relationship with her Dad now feels good. In the past Sam said she has been a mediator for him with her brother and mom. We reflected on her self-care strategies and strengths.  Sam felt that having space from her family has been helpful. I validated how important boundaries are for self-care. Sam talked about how she had been a victim to her dad’s alcohol use, and related abusive behaviour. I acknowledged how difficult it is to have a parent with an addiction as you never know what to expect, sometimes they can be very loving and supportive but other times they are abusive. This psychoeducation came from Heller who explains how when parents are distracted or preoccupied with their own unresolved relationships histories children cannot figure out what makes the relationship good or bad, they are constantly trying to rearrange themselves to fit the parents’ changing moods and responses. “Or they attempt to manipulate or control the parent to eke out the positive merging, support and/or love” (2013, p. 10). Additionally, I felt that Brier et al. refer to the importance of developing boundaries in saying how individuals who have lived with childhood trauma experience an inability to access the internal sense of self such as; determining one’s owns needs, a consistent sense of self, having an internal reference point at times of stress, and a positive sense of self (2014, p. 198).  
2. Sam started to experience insomnia since our previous session, including generalized stress and worry. She described “new chest pain, palpitation” for approximately the past week. Sam has had some of these symptoms in the past but never this long (medical follow up was discussed). She has been experiencing general worry about school, but overall, no specific concern having, “anxiety about having anxiety”. Normally Sam said she “love[s her] night routine”, but felt “manic” at 2 am when unable to sleep. We explored possible trigger’s focusing on Sam’s internal senses; “big to do list, pressure to do well”, “shoulding self, and pressure to be social”. Sam also talked about having “OCD behaviours” regarding contamination, engaging in excessive cleaning and hygiene. We reviewed her strengths and self-care strategies of having a night routine including yoga, nighttime tea, a quiet independent space. Sam worries that her mental health will start to effect school. She is taking three classes and compares herself to others who are taking 6 making her “feel incapable”. During this session we reflected on how harsh this internal dialogue is and wondered how she might be more compassionate with herself? Sam reflected on how difficult this was for her. When CBT strategies did not seem effective as Sam said she understood how to be more compassionate but did not want to be. We focused on a childhood memory in which Sam felt a lot of responsibility and in this memory, Sam was able to feel compassion for her child self.
3. During this next session Sam was still struggling with sleep and anxiety. Sam was started on a SSRI the past week by her provider. This was difficult as Sam remarked “I don’t like taking drugs”. Having a fear of substances when seeing her brother and dad struggle so much. We explored herself narrative when Sam is up at 5 am unable to sleep, she has been asking herself “what do you need?”. In response her thoughts include feeling overwhelmed, stressed, feeling helpless and angry, lonely.  When breaking overwhelm down further it included thoughts of being “not good enough, not doing enough, and a imposter syndrome”, and not meeting her level of ideal achievement. She also said her family has been so supportive which “makes me angry at myself”. We brought awareness to how critical this voice sounded and the tendency to push herself. Sam noted that this has been a lifelong pattern and she feels afraid to change out of a fear of failure, feeling that the anxiety drives her success.
4. In the next session, Sam said that her anxiety seems to be slightly lower, but that it is still present, and she continues to worry about sleep. Sam also picks at her skin and this has actually worsened, she is pulling at her skin until it is bleeding and using objects to pull skin back, even picking in her sleep. We focused today on exploring and breaking down this thought and behaviour pattern (drawing from trauma informed CBT practices); Sam noted a fear of lack of control, “I can’t let things go”, things felt chaotic in childhood, “felt like wife to father and friend to mom”. Sam expressed awareness that if she wasn’t responsible as a child, she “could have ended up like [her] brother”. Sam also love’s the way picking and obsessive cleaning feels; noticing a sense of “release”, feels she achieved something, and that she can take something off her plate, feeling relaxed after, she also described a sense of control. We explored what else might offer this sense of control, release, and achievement. Sam made a plan to explore mindfulness activities and delay picking by using a mindfulness colouring book, and short meditations. We also explored the qualities of a what a competent protector would have been like in her childhood. We explored how her childhood might have felt different. Sam felt she would have had healthy boundaries, and would have experienced increased emotional protection, not having to grow up so early. Sam said she also would have felt like a priority.

Conclusion

            I have found that attachment theory and somatic trauma informed practices seemed to be a good fit for Sam. Sam is an extremely insightful client and has education in psychology which seemed to help ground her and trust in our work together. Additionally, she has strong self-care practices and many strengths, many of which allowed her to survive her childhood. I did not find solution focused or CBT practices to be as effective and I believe this was because Sam was carrying such strong imprints from her childhood. If Sam were to allow herself more emotional freedom the risk felt too high, that she might end up like her brother who creates additional stress on her parents. I do not necessarily believe that Sam would become dependent on her parents if she did allow herself more emotional freedom. Likely these childhood dilemma’s need to catch up with her current adulthood. My hope is that Sam will discover that pushing herself as hard as she needed to in childhood is longer necessary. This may require her to develop some new relationships in which emotional support is available. I am hopeful that the competent protector visualization will help her with this. However, I do understand that it is important to work slowly on changing these patterns given the strong nature of childhood imprints. I did feel that reflecting on Sam’s childhood, feeling compassion for her younger self, imagining competent protection all created new possibilities for how she might feel more support and comfort in the world. My goal is to continue to practice and explore these attachment based somatic practices with Sam to see how we can slowly build greater self-compassion in her present life. I could also see how Internal Family Systems and EMDR could have been a good fit for Sam but I am only starting to learn how to work with these practice models.

Resources

Bell, W. C. B. (2015, March 10). Hope, trauma and resilience: a conversation about vulnerable                children in America [Keynote address at the 2015 Kevin J. Robinson Forum on Social                        Justice]. Resilience in the Face of Childhood Trauma, Philadelphia, United States of                        America.

Briere, J. N., & Scott, C. (2014). Principles of Trauma Therapy: A Guide to Symptoms,     Evaluation, and Treatment ( DSM-5 Update) (Second ed.). SAGE Publications, Inc.

Heller, D. P. H. (2013). Navigating the Labyrinth of Love – How Attachment Styles Sneak into      Adult Relationships. Https://Dianepooleheller.Com/Wp-Content/Uploads/2018/12/Navigating-the-Labyrinth-of-Love.Pdf.