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CASE STUDY ONE: AN AGENCY GROUP SUPERVISION SESSION

The case

The case is that of a young Indian man Anil. He is 37 years of age, married with two children aged 14 and 7 and living in East London. Anil has a large extended family. Family members live in close proximity to each other in five houses in the same street. Anil came to England at the age of 6, to live with his parents. He was born with a cleft palette and underwent corrective surgery, but his speech is often difficult to follow.

Anil attended mainstream primary school and transferred to secondary school. At secondary school he was diagnosed as having learning difficulties and moved to a special school. When he left school, his mother found him a job and took charge of his earnings. Although Anil wasn’t happy in the job, he stayed in it for 10 years. However during that time he also found ways of making himself unwell so that he didn’t always have to go to work. His self-harming behaviour escalated over the years. He took rat poison, cut himself and did risky things like climbing on rooftops. He also started behaving aggressively to his wife and parents and, some times, to complete strangers. His behaviour brought him to the attention of the police.

Anil has been in the mental health system for 15 years. The psychiatric team involved with his care strongly believe that Anil’s behaviour is a response to family dynamics. Their view is that family work offered the best hope of understanding and changing his behaviour. Anil’s family on the other hand believe that medication is the answer. Their view is that the psychiatric team could do more to help Anil. They therefore asked their local Member of Parliament (MP) to intervene with the psychiatric team.

The supervisee and her dilemma

Juliette, is white, British and a clinical psychologist in a Community Mental Health Team (CMHT). She is the case co-ordinator and has been working therapeutically with Anil and his family for approximately18 months. She has noticed that Anil is increasingly unable or unwilling to use therapy and is preventing his wife and other family members from using the sessions with his aggressive and intimidating behaviour.

Juliette’s colleagues in the CMHT feel there is nothing more they can offer Anil and his family. Her manager has told her that she should close the case. On one hand the thought of closing the case is a great relief to Juliette. On the other hand she wonders whether there is more she could/should to for this family.

The peer group discussion

Areas explored in the supervision group were:

- What work was being contracted for and with whom.

- How race, culture and immigration might have impacted and may still be impacting on Anil and his family.

- The family’s religious beliefs (this is a Hindu family) and how these might inform their expectations about what should/could be done.

- What were the issues around keeping safe and how were these being managed for the family, members of the public, CMHT professionals

- What were other services responsibilities in relation to Anil and his family.

The peer group discussion validated Juliette in her own practice as she acknowledged that their conversation echoed many she had had with herself, with colleagues with Anil and with members of his family.

Supervisor’s contribution

Facilitating a discussion in which issues can emerge for exploration, is one aspect of the supervision role. Another is offering supervisee’s a theoretical framework for thinking about some of the dilemma’s they encounter in their work. The theoretical framework offered here was Domains of Action Theory, which allows professionals to think about how they are positioning themselves and being positioned in different interactions and different relationships.

The dilemma Juliette brought to the group, framed as a question, was “Have I done all that I can before closing this case? Juliette’s line-manager had given her permission to close the case. Her colleagues agreed she and they could do no more for Anil and his family. However, in asking the question “have I done all I can for this family?”, Juliette is highlighting that accountability has a wider audience than her line-manager and team colleagues. Her question foregounds two other questions (a) what does it mean to close this case? and (b)what are the other views that need to be taken into account before the case can be closed?

In the supervision group Juliette and her peers started a discussion on who, in addition to her line manager and team, might be the audience to which she should be accountable. They identified:

Juliette herself in terms of her personal beliefs and professional ethics

Anil

Members of his family

Anil’s GP

The MP

The police

Members of the public

Naming the people who may be more or less affected by the decision to close the case, enabled them to explore differences in expectations, duties, responsibilities and obligations and with it a range of actions around how the case could be closed.

Supervision, therefore enabled Juliette to enter into a different conversation with her line-manager about how she would handle closing the case that would be congruent with her personal and professional beliefs and fit the agencies policies and procedures.



Dr. Sharon Bond
Consultant Systemic Psychotherapist

CASE STUDY TWO: COUNSELLING IN A PRIMARY SCHOOL

This example is of work with a child who was in danger of being excluded from primary school.

The case

James, a 7 year old boy of African-Caribbean heritage was in his second primary school when I first met him. James’ mother had removed him from his previous school where he was on the verge of being excluded. James’ old school was just across the road from where he lived. He had not yet settled into his new school. He missed his friends who he saw in the evenings when her returned from his new school.

James’ new school described him as verbally and physically abusive with a bad temper. They said he found it hard to stick with tasks and got very little work done. Whatever little work he did, he destroyed by scribbling all over it and tearing it up.

James agreed that he had a temper. He said he was ‘hard’ because people were scared of his temper. James liked people to be scared of him but he also wanted them to be friends with him.

James’ mum worked for the Post Office which meant she did shift work and would sometimes be gone early in the morning before James was up for school or return home in the evening after he had gone to bed. She had a good relationship with the head teacher at James’ new school.

The work

The school didn’t want to exclude James but they wanted his aggressive behaviour to change. I had an idea that James’ problem was that he didn’t know who he was and therefore what he could and could not do. I based this on the fact that when James and I first met although he looked 7, he acted like a 14 year old. The work, as I saw it, was to help James find out who he was so that he could choose to behave differently.

I met with James fortnightly for one hour during term time from October to July. The work I did with him can be described as going through three phases. Phase one was working with James to help him talk about his temper instead of acting it out. Phase two was working with James to identify and give voice to his different identities so that he could choose who he could be. The final phase focused on getting James to chose ways of behaving that were more acceptable to school and which benefited him. I used Michael White’s ideas about externalising the problem to help James see himself and the problem of his temper as separate.

Phase one - James’ identity as a person with a temper.

I combined drawing with the use of play-dough. I asked James to draw what he looked like when he was in a temper. Then I got him to use the play-dough to make his temper. We talked about the temper as separate from himself. He gave it wings. He learned to manage it and finally allowed it to fly away.

Phase two - James’ identities as a carer, a resourceful and independent person

By this phase James was much more in control of his temper. Our conversations were now about his homelife and the different people in his life. James talked best when he drew. He drew getting up in the morning, we talked about who was there, what he did, how he took care of himself and others and his journey to school.

James loved being in school. He lived quite a distance from school and liked to get there on time. However, because his journey took two buses he sometimes got in late and this would upset him. On his journey to school he sometimes had to make decisions, like does he stay on the bus and be late or get off and have to walk past the man with the big dog that frightened him. Some of the decisions he had to make (like the one with the dog) meant he had to be strong and courageous even when he didn’t feel that way inside.

Talking about this helped James to see himself as resourceful, but also to acknowledge that he was a child and it was OK to be afraid and not have all the answers. James was transforming himself. Gone was the 7 year old going on 14. He had turned 8 and was acting like an 8 year old.

Phase 3 - James’ identity as a negotiator

By this phase James was not sure whether he should still be coming to see me. The school recognised an improvement in his behaviour but thought he could do even better. James seemed to enjoy coming and make good use of the time we spent together. This made me think his worry about seeing me was more about what other children thought about him coming out of class to see me. The Special Education Co-ordinator (SENCO) and I agreed that when James didn’t want to come to a session, he would have to come and tell me himself.

I called this developing his negotiation skills. James liked the fact that he could negotiate, and the school begun to see him as a person who could negotiate rather than act out. I learned that a part of James problem was his relationship with his class teacher. I asked him if he would like her to come to one of our sessions but James said no. He thought that his teacher didn’t like him and was worried about what she might tell me.

I thought it important to have James’ teacher’s input if we were going to change their relationship and his behaviour. I also thought it important that James had a central role in how that happened.

As part of the process of negotiating with James how we would manage to include his teacher, I showed him 32 questions we could ask his teacher to find out what she thought about him. The questions were multiple choice. I asked him to pick the 10 he would most like her to answer. An example of the kind of questions he had to choose from is given below:

His teacher had to put a tick against the answer she thought best showed his ability.


I wrote a letter to James teacher enclosing the questions. I asked James to give it to her and to bring her reply in the envelope I’d enclosed in the letter for our next session.

James and I looked at her responses in the next session. James was surprised at his teacher’s positive views about him. He was able to say that he knew he sometimes pushed her away when she was trying to help him and that made her sad.

James’ behaviour changed significantly after this episode. The school thought he was a different child.

Attached is the certificate presented to James, in assembly, in recognition of his achievement.