The Secret World of Maya Alexander

Chapter 31

Reading through the counselling referrals was an everyday part of Emily's morning routine. But when she saw the re-referral for Maya Alexander she felt a little sinking feeling in her stomach. There were often people who returned to counselling; some people just seemed to need that space to talk to keep them going. Maya had seemed different. Even though she had used the space to talk, the therapist felt that there was a distance that had remained between them. It was as though Maya was going through the process, but choosing her words carefully.

Of course, Emily had also  been careful about how she had written her notes on the sessions with Maya, keen not to make bold formulations which could have been deemed presumptuous. Maya was a Psychologist and she recognised that this had made her a little more nervous about her practice. She wondered whether this was the reason that Maya had seemed closed and guarded. That maybe  it had been her own anxiousness about saying and doing the correct thing had been the thing that stopped Maya from being able to speak openly.

She re-examined the case closure notes that were at the front of the file:

Name: Maya Alexander
Date of session: 21st June 2018
Reason for request: miscarriage
Number of session: 5/5

Summary of session
Case Closure Summary

Reflections about the process:
Maya talked openly today and as the sessions have progressed she has seemed more engaged in the process.
She has been most responsive to solution focussed approaches rather than reflecting back and narrative approaches.

Miscarriage:
Throughout the sessions she has only spoken briefly of her miscarriage.
When talking of the miscarriage she seemed to express that she believed that the loss should not have had a significant impact.
M:'I was only 18 weeks pregnant... well not even that really as the baby had already died.'
I wondered whether these were her thoughts, or a feeling she had gained from elsewhere?
She seemed to close down when I tried to explore this idea or talk about loss and grief being an individual experience.
M: 'Oh, yes, I know that. I think for me it was just that I was in shock at first.'
When I checked out the idea of 'shock' being temporary and the request for support coming a couple of months later Maya again seemed to close this down.
M: 'Well I suppose everyone has an individual response.'

Maya briefly mentioned the loss of her father in a house fire, when she was a child and how she thought she had struggled with this and that maybe the miscarriage had resonated with this time. Again when I tried to extend discussion about this Maya seemed to close off the need to think about this further.
M: 'I suppose just having the chance to recognise that it may have been something which was having an impact is helpful enough.'

Relationships:
Time was spent in each session exploring sources of support for Maya.
Maya was able to name people in her life who were her sources of support. These included her husband, Stephen, her mother, Jackie, her sister, Alice, her colleagues in work, Marge and Helen in particular, and also her friend Charlie from university.
When asked how these people supported her, she seemed more vague in her responses.
M 'Just in the usual way family and friends support you.'
Again I tried to unpick this
E: 'What are the usual ways?'
M: 'Well I guess it depends. It is not about them anyway. They are all fine. I was the one referred for counselling'
E: 'What do you think you needed from counselling?'
M: 'To be able to move on.'
E: 'Do you think you would find it helpful to focus more on 'moving on?'
M: 'Yes, in fact I think I already am. I think that's why I may sometimes find it hard to answer all of your questions. I think focussing on what could be wrong might just make me overthink things and dwell. I feel like I am coping a lot better now when I focus on moving forward.'

Although Maya seemed reluctant to explore her loss and the support systems that she had, she was able to acknowledge this reluctance and expressed a desire to focus on moving forward and we therefore agreed to shift to a more solution focussed approach.

Response to Solution Focussed approaches:

This seemed to work best for Maya and she definitely seemed more relaxed during these sessions and when questions were about signs that she was moving forward. This seemed to be a much 'easier' conversation to have with Maya and she actively engaged in these sessions.

Coping Strategies:
Maya sometimes talked about connecting with nature when we explored coping strategies and what helped her feel more calm and relaxed.
M: ' I sometimes imagine I am close to the ocean and listening to its waves swaying back and forth as I breath in and out'.
We reflected upon how this may be a meditative process for Maya which she used to 'self-soothe'. I noticed Maya seemed to relax as we validated this strategy. She hinted that other people in her life may have been less supportive of this form or coping mechanism.
M: ' I like that idea. If only everyone could understand that. My mum and Stephen always seem to worry about me needing time for myself.'

Scaling:
During the sessions, Maya rated herself consistently between 6 and 8 on how well she felt she was coping.
She seemed particularly honest and positive during the final session.
M: 'I think I am at a steady 8. Things are not perfect yet, but I feel that I can move on from disappointment better.'
E: 'What would I notice if I bumped into you in the street and you were at a 9? What would you tell me?'
M: 'I think I would be back to my full workload and maybe me and Stephen would have just come back from a lovely holiday in Italy!'
E: 'What would be your first steps in making that happen? How would you know you are moving towards 9? What would be the first sign?'
There was quite a pause here.
M: 'The first sign would be that I have a lovely evening with Stephen today, as it is his birthday.'

Summary:
Maya seemed realistic and hopeful. She has been able to make good use of solution focussed approaches during the sessions. We have not been able to spend much time unpicking the sources of her distress, however this did not seem to be something Maya was able to undertake at the moment and which she did not find helpful in the initial sessions.

Close current involvement? Y/N

Reason:
Maya has engaged consistently during the last 3 sessions and is able to acknowledge coping strategies and signs of hope.
We talked about routes to access further support if needed.

As Emily read through her case summary she wondered how much it reflected back what had really happened in the sessions. Had she really believed that Maya was hopeful and positive and that focussing on what was going well and moving forward was what her client had needed? What had made her so convinced of this? Had Maya's own self-reflection been so powerful that she, as a therapist, had not seen the need to explore them further? Had she misjudged the balance between acknowledgement and deepening discussion? Why had she felt a lump in her throat when she had seen the re-referral Maya Alexander?

Emily decided to talk it through in supervision.

'What is it about this case that has made you concerned?' Jane asked

'I am not sure if it is any different from any case where you have a feeling you have not been helpful.' Emily reflected 'I just felt there was more beneath the words but I couldn't get to them'

'Do you think it is always possible to get 'beneath the words?' To be helpful?'  It was a rhetorical question as they both knew the answer.

Emily answered it anyway. 'No, I know. Sometimes you go forward, sometimes you go back. Sometimes you just stay where you started.'

The words were not hers. In fact as they came out she recalled that Maya has said something similar about what it felt like when she used to imagine watching the ocean.