Case Study 4 Case Study 4 Asynchronous computer-mediated support for clients accessing an independent private practitioner Case study 4 presents Nasrata, who is 25 years old. She contacts the practitioner by email after locating the online counselling website which the Steph, the practitioner, has recently published on the Internet. The clients presents in the following manner within her initial email: Hello, I feel that I need some personal counseling to help with some problems I am facing in work and personal reltionships. I suffer a lot with anxity and need help to calm me down when this happens. I canвЂ™t even get out of bed some mornings cause I feel so low. Ive started drinking at night to help me sleep and IвЂ™m worried my family will find out and say I need to go back home to live.they are very protectice of me and I just want them to leave me to get on with my life. I never used to have problems with anxity until I went out with a guy who was very verbally abusive to me and since then it just seems to get worse. It was really difficult to get out of the relationship, but we seperated a couple of weeks ago. I think I may lose my job if I donвЂ™t sort things out. They have noticed that IвЂ™m a bit groggy in the mornings and I think they might have realised that IвЂ™ve been drinking the night before. Can you help with anxity..if so then perhaps I can arrange an appointment with you. Nasrata StephвЂ™s initial responses to receiving the client email: вЂў Steph feels unsure if the client has some literacy difficulties which may have affected the spelling of words within the email, or that the client may have been drinking when she wrote the email (as she has mentioned that she has begun drinking at night). вЂў Steph feels a little unsure if online counselling may be able to provide the level of support the client requires as she has a sense that the client may be at risk, or experiencing depression. вЂў The client mentions that she has experienced an abusive relationship which steph anticipates may have been more than verbally abusive. вЂў The client feels quite isolated in many ways and Steph is unsure if remote counselling may only serve to compound this. How do StephвЂ™s initial thoughts match or differ with your thoughts and feelings regarding the clientвЂ™s presentation within this first email? How would you proceed? The following slide looks at StephвЂ™s approach and initial email response to the client. First email reply: assessment and contracting stage Dear Nasrati, Thank you for contacting me for online counselling support, and also for the detail you have provided within your email regarding the aspects of personal issues which are affecting you at the present time. I can hear how upset you feel regarding the level of anxiety you are experiencing and how this is impacting upon your personal and work life. I can also hear how you are concerned that both yourself and others are noticing that the anxiety has reached a point where you need support to regain a sense of control in your life. When I initially reply to clients I like to check out that online counselling is the most suitable way of a client getting the support they need, so I would like to ask you a few questions to see if I will be the best person to offer you that. If you are uncomfortable with any of my questions, or feel unclear about anything, then please let me know. Can you please consider the following questions when constructing your next reply: Have you spoken with your GP regarding the level of anxiety you experience since the break up of your relationship. If so can you provide me with information regarding the outcome of this? You mention that you have started to drink alcohol in the evenings to help manage the anxiety. Would you say that this affects how you might be able to engage with counselling if writing emails when you have been drinking, or would you be prepared to write your replies without having consumed alcohol? ( I ask this question as I feel that it can affect thought processes and memory if clients write their emails when under the influence of alcohol.) First email reply (continued) Are you receiving any support from other agencies regarding the anxiety or any other personal issues you have mentioned? If so, could you provide me with information on the support you are receiving? Do you feel that online counselling would be your preferred option of counselling support, as opposed to meeting with a counsellor in person? I hope you donвЂ™t experience my questions as intrusive in any way. I would like to offer the reassurance that I have asked them so that we can both decide if the support I can provide will be the best option for you. IвЂ™ve included a link here for a website which offers support to people with anxiety. You might like to check it out and see if thereвЂ™s anything that seems helpful whilst we are in the process of deciding if I can offer the help you need. Website link: http://www.nopanic.org.uk/menu.htm Kind regards, Steph Points for Discussion вЂў What are your initial reactions to StephвЂ™s reply to the client? вЂў How might you have structured a reply in a different manner? вЂў How do you anticipate the client may have experienced the content of the reply? The following slide contains NasratiвЂ™s reply NasratiвЂ™s email reply following StephвЂ™s initial email response Hello Steph, I donвЂ™t mind answering your questions. I can understand that you would need to know more about me and whatвЂ™s upsetting me to see if you can help. Thanks for the website link. It was really helpful. I also rang their helpline last night. I have been to my GP and they have given me some anti depressant. They thought I was depressed more so than anxious. I have felt realy tired since I started taking them so I donвЂ™t think thatвЂ™s helping with how I feel or getting up for work. In respect of alcohol, I would write my email reply early in the evening or at weekends so I donвЂ™t think this would afect how I write them or what I say. I was referred to a nurse a while back (2 years ago I think) when I was depressed and I use to have to see them once a week. They used to come to my flat to check I was okay. This time things are not so bad nd now ive finished with my boyfirend I think this will help. I would prefer online counselling as I think this would fit in better with work and I can always think about face to face counselling after a few sessions with you if needed. StephвЂ™s thoughts after receiving the clientвЂ™s second email вЂў The client had provided reassurances that she was willing to seek the support of a GP when required. This led Steph to believe that if the clientвЂ™s mental health deteriorated during online counselling, she would be open to a suggestion of re-visiting the GP practice. This would enable Steph to be able to fulfil the required duty of care to the client. вЂў The client had provided reassurances that she would write her email to Steph without having consumed alcohol. вЂў The client had been open regarding a previous incidence of mental health difficulty where she had received the support of a mental health nurse. The client was also able to clarify that the way she was experiencing the current depression was not as bad as the previous incident. вЂў The client had confirmed that online counselling was the preferred option at the present time, and also mentioned that she would consider a face-to-face option at a later point if needed. Based upon the clientвЂ™s reply, Steph decides that it would be appropriate to offer online counselling with the client and replies to Nasrata with a suggested contract for their work. Points for Discussion вЂў Do you agree with StephвЂ™s decision to proceed in offering the client online counselling appointments? If you disagree discuss the points which have brought you to that conclusion. вЂў What additional information might you have requested from the client, or what aspects would you have omitted from StephвЂ™s online assessment of client suitability to be supported via a computer-mediated facility? вЂў The next stage of engagement with the client would be the contracting phase. Based upon the clientвЂ™s presenting issues and the general considerations of what is pertinent to include within such contracts, what main elements would be included within the contract? You may find it beneficial to have read Chapter 6 of the book before conducting this discussion.