Part A 10-minute Transcript of a 30-minute face-to-face counselling session

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Part A: 10-minute Transcript of a 30-minute face-to-face counselling session 1. Segment One: Brief overview of the case  Mary, a 35-year-old, married, childless woman, was referred for treatment of depression following the death of her baby girl in utero at 26 weeks’ gestation. Her doctor explained that a bacterial infection was the most likely cause of the miscarriage. Mary’s chief complaint was: “I feel like I should be over it.”  At 27 weeks, after not feeling the baby move for at least several hours, Mary called her doc-tor, who told her to come to the hospital. The doctor was unable to find a heartbeat and told her that he needed to deliver the fetus. Mary re-called feeling shocked, numb, and unable to cry at first. She was given medication to induce labor and an epidural, and delivered the baby vaginally.  Despite efforts to revive her, the baby was pronounced dead shortly after delivery. Mary said that she wanted to hold the baby and was given the baby to hold.  Mary reported that since the miscarriage 2 months earlier, she had been feeling sad and irritable most of day, nearly every day.  Being a nurse, Mary feels hard to work as a group with fellow medical practitioners, friends, and neighbors. Mary reported that she tried not to think about the baby’s death, but she was frequently bothered by thoughts about the baby, often.  Mary reported that she had avoided returning calls from old friends. She explained that she did not feel comfortable seeing her friends who had babies, because it would remind her of the baby she had lost. Mary also did not want to have to talk about the loss.  After the stillbirth, Mary seems to have developed post-traumatic stress (PTSD). 2. Psychotherapy Modalities For the case of Mary, how suffers PTSD, the following modalities would work: Cognitive Restructure Therapy (CRT); Thought records, and Interpersonal psychotherapy. 3: Face to face counselling session 3.1. Ten (10) Minutes session on demonstration of thought records The session began with Mary describing the “sad feelings, shame, insomnia, angry, and guilt” she was having. The therapist al-most immediately started to elicit Mary’s automatic thoughts during these periods. Therapist: First I will get you’re provides an excellent way to capture faulty thinking and begin the process of cognitive restructuring. Therapist : What kind of thoughts go through your mind when you’ve had these sad feelings this past week? Patient : Well, I guess I’m thinking what’s the point of all this. My life is over. It’s just not the same. I have thoughts like, “What am I going to do? Sometimes I feel guilt at my friends,

when I think about my baby, I don’t get good sleep. How could my baby die like that, every time my friends ask about the baby I get irritated and aggressive? Therapist : It sounds like you are feeling quite bad right now. Is that right? Patient : Yes. Therapist : Keep telling me what’s going through your mind right now? Patient : I can’t change anything. It’s over. I don’t know. . . . It all seems so miserable and hopeless. What do I have to look forward to sickness and then death? Therapist : So one of the thoughts is that you can’t change things, and that it’s not going to get any better? Patient : Yes. Therapist : And sometimes you believe that completely? Patient: Yeah, I believe it, sometimes. Therapist : Right now do you believe it? Patient : I believe it—yes. Therapist : Right now you believe that you can’t change things and it’s not going to get better? Patient: Well, there is a glimmer of hope, but it’s mostly. Therapist : Is there anything that you kind of look forward to in terms of your own life from here on? Patient : Well, what I look forward to. I enjoy drinking wine to forget the past. 3.2. Ten (10) Minutes session on demonstration of Cognitive Restructure Therapy This is the last CRT session with the patient. Therapist: Mary, do you mind if I ask you a few questions about this thought that you noticed, “I should have had them wait and not had them go on?” Patient: Sure. Therapist: Can you tell me what practice you can adopt to cope up with bad situation like death? Patient: Reach out to people you trust and help others dealing with the loss. Therapist: Have you tried to reach out to any? Patient: No. Therapist: Why? Patient: No. I still fear guilty. Therapist: Okay. So, prior to the death, you hadn’t had any close family member that you loved then died.

Patient: I have. Therapist: What did you do to cope up? Patient: I accepted the feeling and become optimistic. Therapist: Can you describe the type of emotion you have when you say, “I accepted the feeling and become optimistic?” Patient: I guess I feel less guilty. Therapist: That makes sense to me. As we go back and more accurately see the reality of what was really going on at the time of this death, it is important to notice that it makes you feel better emotionally. In fact, I was wondering if you had ever considered that, in this situation, you actually did exactly what you were supposed to do and that something worse could have happened had you chosen to make them wait. Patient: No. I haven’t thought about that. Therapist: Obviously that was the moment you have waited for long to get your first baby. Is it possible that it could have gone down worse had you delivered properly as expected and have your first baby? Patient: Hmmm. I hadn’t thought about that either. Therapist: That’s okay. Many people don’t think through what could have happened if they had chosen an alternative course of action at the time or they assume that there would have only been positive outcomes if they had done something different. I call it “happily ever after” thinking — assuming that a different action would have resulted in a positive outcome. When you think, “you delivered as expected and had your baby right now,” how does that make you feel? Patient: It definitely makes me feel happy. Therapist: I’m wondering if there is any pride that you might feel? Patient: Hmmm...I don’t know if I can go that far. Therapist: What do you mean? Patient: It seems wrong to feel pride when my baby died. Therapist: Is it possible to feel both pride and sadness in this situation? Do you think your lover would hold it against you for feeling pride, as well as sadness for his and others’ losses? Patient: My lover wouldn’t hold it against me. In fact, he’d probably reassure me that I tired.

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Therapist: That seems really important for you to remember. It may be helpful to remind yourself of what you have discovered today, because you have some habits in thinking about this event in a particular way. We are also going to be doing some practice assignments that will help to walk you through your thoughts about what happened during that event, help you to remember what you knew at the time, and remind you how different thoughts can result in different feelings about what happened. Patient: I actually feel a bit better after this conversation. 3.3. Ten (10) Minutes session on demonstration of Interpersonal psychotherapy IPT Middle Phase (Sessions 4–9): During the middle phase therapy, I will worked with you to resolve your interpersonal problem area. In IPT, the strategy for working with grief is to help you to tolerate and manage the effect of loss, and to gather social support to help the patient through mourning. T herapist : The first trimester of pregnancy can be really difficult and disruptive. Give your- self a break! It can be hard to appreciate being pregnant when you are feeling so terrible. It sounds like you did appreciate being pregnant you made a great effort to take care of yourself. You watched your diet care-fully and rearranged your work situation. : I don’t know . I guess that is true, it me who led to the death of my baby. T herapist : What could you have done to pre-vent your baby’s death? Patient: (tearfully) I don’t know. I should have been able to do something. The therapist offered Mary empathy and support, and related her guilt to depression: T herapist : It would be great if there was some-thing you could have done to prevent this tragedy, but there is generally nothing parents can do to prevent a pregnancy loss. It sounds like you did everything you could—you took very good care of yourself. You are struggling with inappropriate and excessive guilt a symptom of depression. You are blaming yourself for something you didn’t do. Perhaps when you find yourself feeling guilty, you can try to label this as a symptom of depression. Patient: Yes. I guess I can try. T herapist : your feelings are not going to hurt you. You might actually feel better if you allow your-self to let out some of the feelings you have been trying to keep inside. I know I am asking you to take a risk, but you might be pleasantly surprised. Patient : I cried a lot. She was so cute. It wasn’t as hard as I thought it would be. It felt like a re-lease. I was surprised that I felt a little better afterwards. T herapist : I am so glad you took a risk and looked. It sounds like it made you feel better.

T herapist : What kinds of things have people asked, or what are you afraid they will ask? Patient: People have asked “How’s your baby?” or “Weren’t you pregnant?” T herapist : How does that make you feel? Patient : Awful! T herapist : How do you handle it? Patient : I don’t know. . . . Sometimes I say “It didn’t work out” or “My baby died.” T herapist : That sounds good. How does it feel for you to say that? Patient: It feels OK, but then they want to know what happened and say silly things like “At least you know you can get pregnant” or “You can have another one.” T herapist : What would you like them to say or do? Patient : I would like them to just say “I’m sorry,” and not ask any questions. I don’t want to talk about what happened. T herapist : How could you convey that? Patient: I guess I could say, “I’m sorry, but I’d rather not talk about it.” T herapist : How does that sound? How did it feel to say that? Patient : It felt OK. Don’t you think that is rude to say that? T herapist : No. You said it politely and it is appropriate for you to assert your needs. It is an uncomfortable situation for both you and the person who asked the question. If you are polite and direct with people, they are likely to understand. But why not try it and see? You need health relationship with people close to you for social support. What happened is beyond them. Patient: I appreciate your advice, I will “push hard” and try to reconnect with others.

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