Case study:

Theo, 35yo, is an experienced builder's labourer and a keen amateur cricketer. He is married to Angie, 33yo, part-time legal secretary, with two children Esther 11yo and Zoe 8yo, both at the same primary school. Theo was injured when a concrete block dividing wall collapsed on a building site for an industrial development (insufficiently secured, windy day). His lower right leg was crushed, leaving him with a badly broken ankle, compound fractures of his tibia and fibula, and significant ligament damage to his knee. His boss Daniel, 46yo bricklayer, was killed beside him, having pushed Theo aside as the wall fell. Daniel's wife Rose ran a caf near the site, heard the collapse, and ran to the site. Theo saw her immediately after the accident, screaming as other workers tried to rescue Daniel (who most likely died instantly). Daniel and Rose have three children: Hamish (22yo, studying law), Callan (20yo, apprentice chef), and Orla (16yo, final year in secondary school).

Theo missed Daniel's funeral because he was still in hospital, recovering from the first of three separate operations on his right leg. He first had a rod inserted in his tibia, then two weeks later his ankle was fused. A post-operative infection in the leg meant that his bones didn't heal despite the best efforts of the medical staff, and seven weeks after the initial operations, his leg was amputated below the knee. Theo spent a further three weeks in the hospital while his wounds healed, and then another ten weeks in a rehabilitation centre, where he was fitted with a prosthetic leg and re-learned how to walk.

Theo was discharged to his home five months after the accident. Over several attempts by his workplace's Employee Assistance Program organisation to set up counselling with Theo, Theo provided a series of reasons for not being able to begin. Three months after he returned home, Angie contacted the EAP service after finding the card in his wallet and urged them to try again.

Crystal is a 27yo EAP counsellor whose employing organisation provides EAP counselling services for the building industry. She was the counsellor who was asked to contact Theo to organise an initial counselling session. She rang Theo, and he agreed to a session with her via Zoom a few days later.

When their Zoom session began, Crystal welcomed Theo, explained who she was and what she does. She let Theo know that EAP counselling is free for him (as his workplace pays for it), and that she can see him for up to four sessions. Theo raised his eyebrows when she said it was free for him, but otherwise didn't ask any questions. Crystal asked him where he'd like to start, and Theo said, "I don't know - what do you need to know?" Crystal asked him to tell her a bit about himself and how he's been going. The following is the transcript of their conversation.

Theo: I've been getting by, I suppose - but I've been better, that's for sure. You know I lost my leg?

Crystal: Yes, I'm very sorry to hear that. I imagine it's been very difficult to get used to.

T: Yep. Having to learn to walk all over again, it's been... I was going to say a pain in the... you know... but mainly it's a pain on my stump. You wouldn't credit how much a leg that's not even there can hurt. And even when I'm not on it. You wouldn't wish it on your worst enemy.

C: The pain sounds pretty bad...

T: It's relentless. It gets so bad I wake up in the middle of the night and have to take something just to get back to sleep. Pretty much anything really - I've got these painkillers they've prescribed me, but half the time they don't even touch it. Sometimes the only thing that helps is a rum and coke, and that's going easy on the coke. It's the only bloody thing that makes me feel half normal.

C: So you find that a drink helps you with the pain?

T: Ah, if it was only one drink then Ange wouldn't mind, would she?

C: So more than one then, I gather...

T: I do what I've got to do to get through it. I'm not a drunk, mind you... like I don't get wasted or anything like that. Just so I can relax and not be scratching at it all the time, and get back to sleep.

C: So you're having trouble sleeping?

T: It's shocking sometimes. I wake up and my heart's pounding. It's like I don't know where I am or what's going on. It's gotten so I'll go to sleep in the lounge so I don't wake Ange. Between that and the scratching...

C: It's itchy, where your leg was amputated?

T: Like you wouldn't believe. The weird thing is it's like I'm wanting to scratch my ankle, and it's not even there anymore, so you can't do it. Sometimes I scratch the end of the stump, which is... well, Ange doesn't like it, and she's forever telling me not to scratch it, and I tell her I can't, and... well you know what that's like. It's not good.

C: So... yes, that's not good. I guess it might help me for you to tell me what a typical day's like for you at the moment.

T: Huh. Well... not much, really. A lot of Netflix, if I'm honest.

C: Which would be a big contrast to before your accident, I imagine?

T: Well yeah... I had two legs then. I could do a decent day's work, play cricket with my mates. Even help around the house, get into the netball practice my girls like to do. Now I'm pretty much useless. Can't do a... thing. Sorry, I was about to swear then.

C: Theo, I don't mind you swearing if that's what needed.

T: Well it might be stronger language than you'd be used to, is all I mean.

C: You might be surprised [smiles]. You were saying about work?

T: Well, I liked it. Hard yakka [work] a lot of the time, but a lot of good laughs at work too. And I was earning pretty good money as well, which... well you know, it's a lot tighter now. I used to do a lot of overtime, especially on the big jobs, and get shifts on Saturdays which were 'extra cash' if you know what I mean. I'm on compo [compensation], but none of that's counted in on it. Who knows what'll happen with work from here, too.

C: Have you given any thought to what you might do for work from here?

T: You what? You think I'm going to put what's left of me out there again? I'm not taking any more risks... I've got to look after myself, I nearly wasn't here as it is.

C: So that must be... really tricky, I imagine? I mean, you liked your work, you liked working itself, and of course you liked being paid too. So thinking you're not going to go back to it...

T: WHAT!? [Theo jumps back and looks away from the screen. He's obviously been frightened. Behind him a woman's face can be seen briefly - it's Theo's wife Angie]

T: What the? You know you can't sneak up on me like that!

Angie: Sorry love... I didn't mean to... I just wanted to make sure you were okay, see if you needed a coffee... or one of your tablets?

T: Look, don't talk about those now, I mean half the things don't do anything, the others you don't want me to take 'cause they actually bloody work. Anyway, I'm talking with this counsellor here...

A: Oh, sorry. Have you told her...

T: Look, just leave us alone will you?

A: But I worry about you, you haven't been yourself...

T: Of course I'm not myself. I'm not all here anymore am I, I mean look at me.

A: I don't mean that, Theo... I just want to help if I can. I want to make sure your counsellor knows what's going on so she can help. [Angie speaks directly to Crystal on the screen] That's what you need anyway, isn't it?

C: Uh... well, whatever will be most helpful for you both, of course... it's up to you, Theo. Would you like...

A: I'm sorry, I'm Angie. Theo's wife.

C: Yes, of course... hello Angie. Theo, would you...

T: Yeah, sure, whatever. You want to talk, Ange, you go for it. You will anyway...

A: I don't want to get in the way here Theo, it's just... I want to make sure you're getting the help you need. You know you haven't been yourself... ever since that day, is what I mean. You used to be funny, you were always cracking the girls up, and me too. You don't joke around with us... there's no laughing anymore, just yelling. And you never see your mates, we'd see them and their families all the time. I could never get you and them away from watching the footy! You don't do anything like that anymore. Ricky and Boris, they ring up, you don't even want to take the calls. I don't know if you're texting them or not - when you're on your phone, I don't know if it's to a friend or with that bloody online gambling. It's like you're... I don't know, it's like you don't even want to be here half the time.

T: Jeez, why don't you tell her what you really mean? Give a man a break, will you? How would you be if you had this?

A: I don't know, Theo, and what's more I can't know if you don't tell me, can I? You sit in the dark and check your phone, you're spending more than we can afford on betting, you drink more than you ever did. And you're not doing those exercises they said you had to do: you said they told you that you won't get better if you don't. You're not even looking after yourself. [A is teary...]

T: What do you mean? How shallow are you? Of course I've put on weight. I can't work, it's not like I can even go for a walk without paying for it with my body in pain afterwards.

C: Theo, Angie, could I just...

A: Oh god, I'm sorry, I've just taken over here, haven't I? And I don't even know your name...

C: I'm Crystal. It's alright, Angie: I can see there's a lot you're wanting to share. I know you want to make sure I can be as helpful as possible Theo. And to you, of course... and your girls: you've got two girls, I think, haven't you?

A, T: [together] Yes, that's right [they laugh as they've spoken the same words at the same time].

T: No, you go, love.

A: Yes, Crystal. Two girls: Esther's 11, and Zoe's 8.

T: They're both more like fifteen year olds, the way they go on!

C: Right, thanks. I look forward to hearing more about them as well. But for now, one thing I still don't know much about is what actually happened... could you tell me more about that day?

A: Look, I might leave you two to it then, is that all right love?

T: Yeah, sure Ange... [Angie waves to Crystal on the screen and leaves the room]... yeah, I don't know, Crystal... I start talking about that and I'll lose it again I reckon [shakes his head, grim-faced].

C: I'm sorry, Theo. What would be easiest in terms of us approaching this, do you think?

T: [sigh] Yeah, sorry. It's just... if those bastards hadn't have been cutting corners on safety, I'd still be working... I'd still have two legs... and Danny...

C: Sorry, Theo... Danny?

T: Danny's the only reason I'm still here. If he hadn't pushed me when the wall cracked... I just froze, he yelled and shoved me, and then he was gone. I could see one arm, watching the others throwing blocks of concrete around, trying to get it out.

C: Theo, I'm so sorry... it sounds awful, to be hurt like that, and to see your friend

T: I wish it was me... when I'm trying to go to sleep, sometimes it's all I can think about. I can't get the images out of my mind.

Questions:

Question 1 a. What are the major issues for Theo that could be addressed in counselling?

b. Which of these issues might Crystal address first in a short-term counselling setting?

c. Which of these issues are more suited to being addressed in longer term counselling and why?

Question 2

create and design a short-term intervention plan for Theo's counselling, drawing on therapies outlined in this subject. Explain your rationale for interventions selected, how they might be used and why they are appropriate for a four-session timeframe.

Question 3

What are some of the critical considerations for Crystal in providing feedback to Theo about the way he presents and potential approaches to treatment?

Question 4

Further along in Theo's counselling, Crystal and Theo mutually agree that Theo would benefit from additional counselling. How would you go about sourcing appropriate referral options - what would you be looking for?

Question 5

What ethical considerations are present for counsellor, Crystal in her work with Theo? In your answer, please consider the setting of EAP, online therapy, and multiple stakeholders (Theo, Ange and the HR manager who is keen for Theo to return to work).