6503-4

The first section is for introducing the client. Please include the following information:

Agency Information Park Place Behavioral

Client information (confidentiality of course) Ella Schultz, 16-year-old White female

Session Number 1

Date 07/19/2024

Presenting Issue (reason for referral) Homelessness, familial abuse, legal issues

Relevant Information Family dynamics, educational and employment history, social and mental health history

Goal of Session

1. Client Goal: To explore options for reconnecting with her mother and navigating her conflicted feelings.

2. Your Goal: To establish rapport, assess safety concerns, and begin formulating a plan for Ella's future.

Dialogue

Please group dialogue together.

Identify (for each section)

1. Theory

2. Tools

3. Skills

Analysis/assessment of dialogue

What was going on?  What were the patient's reactions to your feedback?  How did the client respond verbally (quality of voice, tone, did the respond better to closed or open-ended questions?) How did the client respond non-verbally (how did you know they were listening? were they distracted? Did they welcome your feedback?)

Personal reactions and self-reflection to the interaction

What were you thinking?  How do you feel the session went?  What could you have done better?  What will you do differently/the same next time?

Trauma-informed care, family systems theory

Theory- Trauma-informed care, family systems theory

Tools- active listening, empathy, open-ended questions

Skills- assessment of safety, therapeutic alliance-building,

During the session, Ella demonstrated discomfort when talking about family dynamics, and in general, there was a sense of wanting stability while fearing going home. The open-ended questions seemed more receptive to her responses, as she allowed herself to be engaged by direct eye contact and nods in the conversation. Non-verbally, she looked attentive but cautious, fidgety on sensitive issues.

I sympathized with Ella, feeling she was passing through quite a complicated family situation. The session went well in establishing initial trust, but I could do better apart from just reassuring her that everything was safe and confidential and on safety planning. Next time, I will continue using open-ended questions that allow Ella to express herself without feeling any pressure to have to choose me. This enabled her to express herself fully and think through her options

Initial Introduction and Confidentiality

Me: Hello, Ella. I’m a Social worker intern here at Park Place Behavioral. Please be advised that everything we discuss here will remain confidential and I have no right to share it with any unauthorized person. Are you okay with that so we can continue?

Ella: Yes, I’m okay with that.

Me: Great, Ella. How are you feeling today?

Ella: I’m whatever just down about my mom but mad about my dad.

Theory: Trauma-Informed Care Tools: Confidentiality statement Skills: Building rapport, ensuring confidentiality

The session aimed to introduce the counselor, explain confidentiality, and start a conversation about Ella's current feelings. Ella responded positively to the assurance of confidentiality, which helped in building initial trust. She expressed her mixed feelings of nervousness and relief.

I aimed to create a safe and supportive environment for Ella to feel comfortable sharing her feelings. The session successfully established initial rapport and confidentiality, allowing Ella to feel secure in expressing her feelings.

Exploration of Family Dynamics

Me: That sounds really challenging. Can you tell me more about your relationship with your mom and dad?

Ella: My dad started drinking a lot after he lost his job, and he became really abusive. My mom always pretended it wasn’t happening, even when I tried to tell her. I left because I couldn’t take it anymore.

Me: It sounds like you’ve been through a lot. How do you feel about your mom now?

Ella: I feel betrayed by her, but I also worry about her. I don’t know if she’s still with my dad or if things have changed.

Theory: Family Systems Theory Tools: Open-ended questions Skills: Building rapport, exploring family dynamics, empathy

Ella responded openly, providing detailed information about her father's alcoholism and abuse, and her mother's denial and inaction. She also expressed her complex feelings towards her mother, indicating betrayal and concern.

While specific non-verbal cues are not mentioned, Ella's willingness to share indicates she was likely engaged and not overly defensive or withdrawn. Possible non-verbal cues could include maintaining eye contact, showing signs of distress (e.g., fidgeting, tearfulness), or displaying openness through her body language.

The session was successful in eliciting detailed information about Ella's family relationships and her emotional responses. It provided valuable insights into her experiences and current state of mind.

I could have asked follow-up questions to explore more deeply how these experiences have affected her current emotions and behavior. Additionally, offering validation and empathy could have further supported Ella in feeling understood and heard.

Assessing Safety and Support Systems

Me: It’s understandable to have mixed feelings given what you’ve been through. Do you feel safe where you are now at the group home?

Ella: Yes, I feel safer here. The people are nice, and I’m starting to get used to it. But I miss my friends from the homeless camp. They were like family to me.

Me: It’s good to hear that you feel safe here. Having supportive relationships is important. Can you tell me more about your friends from the camp?

Ella: There were a few girls I got really close to. They helped me a lot, and we looked out for each other. I miss them, especially one girl named Marisol.

Theory: Trauma-Informed Care, Family Systems Theory Tools: Open-ended questions Skills: Building rapport, assessing safety, exploring support systems

The session aimed to assess Ella's current sense of safety in the group home and explore her support systems, both in her current environment and from her time in the homeless camp.

Ella responded positively, indicating that she feels safe in the group home and appreciates the supportive environment. She also expressed a strong emotional connection to her friends from the homeless camp.

I aimed to provide a safe space for Ella to discuss her current feelings of safety and to explore her support systems. I wanted to understand how her past relationships impact her present sense of security and well-being.

I could have asked follow-up questions to explore more deeply how her relationships with friends from the camp continue to impact her emotionally. Additionally, offering more validation and empathy could have further supported Ella in feeling understood and valued.

Setting Goals and Next Steps

Me: It sounds like those friendships were really important to you. I’d like to help you think about how you can maintain those connections safely and explore your feelings about reconnecting with your mom. What would you like to focus on first?

Ella: I think I need to figure out what to do about my mom. I feel so confused.

Me: That makes sense. Let’s take it one step at a time. We can explore your feelings and come up with a plan that you feel comfortable with. How does that sound?

Ella: That sounds good. Thank you.

Theory: Trauma-Informed Care Tools: Goal-setting Skills: Building rapport, setting collaborative goals, active listening

Ella responded positively, indicating a willingness to explore her feelings about her mother and to develop a plan with support. She expressed gratitude and readiness to proceed.

While specific non-verbal cues are not mentioned, Ella’s verbal agreement and expression of gratitude suggest she felt supported and understood. Potential non-verbal cues could include nodding, eye contact, and relaxed posture, indicating engagement and acceptance.

I aimed to provide structure and support for Ella to articulate her goals and take actionable steps towards addressing her feelings about her mother. I wanted to ensure she felt heard and empowered to make decisions.

The session was successful in helping Ella articulate her immediate priority and in providing reassurance and a plan to move forward. It laid a solid foundation for continued exploration and support.