[March 2016] Ethical Practice

The previous month was a difficult month. I was coping with an ex-partner expressing suicidal thoughts owing to the end of our relationship and I had no mean to dissuade her from it. Knowing her personality, I knew when she set her mind to it, there was nothing anyone could do. I felt being held hostage when she made it a point to hide this side from everyone else but me. I felt so helpless 6000 plus miles away. While I have always believed that no one is responsible for someone's decision to end one's life, I realised it was easier said than done when it happened on oneself. For that few days, I felt not only trapped by this sense of responsibility over a significant other's life, but also a sense of absurdity of having had worked with clients previously who had been in a similar situation and telling them that it was not their responsibility but yet now feeling so laden with it.

I have always prided myself for being able to deal with work separately from personal life thus far. But this time round, I was no longer able to differentiate between the two. All the settings that I am having my clinical practice this year deals with self-harm and suicidal clients. It almost felt that I was dealing with this theme 24/7; both professional and personal. The line was starting to blur between the two domains. I broke down after receiving another suicidal thought message on a Monday morning where I was due to see an adolescent who had been grappling with suicidal thoughts in the afternoon. I really did not think I could handle it anymore. I did not thought it would be right for me to see the client given my current state and thought of rescheduling the session. I sought the help of a colleague to convey the situation to my supervisor as I was too distressed to manage it.

My supervisor met up with me in the afternoon and we processed it. I was grateful that my supervisor chose to attend to me as an individual instead of a trainee at that moment. Now that things had settled down more, I thought the biggest learning point was being mindful when we might be treading on unethical practices. I had also reflected on how much easier it was to be on the therapist's seat exploring challenges than to be on the receiving end. It was one thing to read and discuss about it in class but another when we are personally involved in such a situation. While there are still much processing to do for this episode, I am glad that I chose to voice my struggles and not proceed with the client that afternoon.

[February] I am a GEMM

I am in the midst of preparing for my reading seminar and thought this was an important entry that I ought to make.

I had chosen the topic of culture initially without knowing what the content of the readings were as I was keen to explore the place of culture in therapy.

When I started to pick up the readings, I thought that one of the readings was very close to heart for me. It had me reflected on a lot of current experiences being a minority here in London.

What struck me was the acronym GEMM – Good, Effective, Mainstream Minority. I have not come across that and perhaps, not necessarily experienced it entirely previously.

In Singapore, I am a member of the racial majority. While I am possibly guilty of participating in racial microaggression, I think by and large, I have been rather respectful of other races and took against outright discriminatory acts. I remember thinking that Singapore is a multi-cultural place where we try to promote and value racial harmony. We generally see our fellow people from other racial groups as fellow Singaporeans than Singaporeans from different racial groups. Or so I thought. I realised I was speaking from a place of privilege. After reading the paper from Afuape, I reflected on this belief and thought that I do not know what fellow Singaporeans from other racial groups have gone through.

This thought was particularly salient when I recounted the experiences I have been having in London. I have been here for one and a half year. To be honest, I do not think anyone has been particularly hostile or nasty towards me because of who I am. But I will say that there had been times I had felt that my ethnicity or accent has influenced how others perceived me and it had not always been comfortable.

To cite an example, I had received more than 10 years of education with English as the medium of teaching. Nonetheless, I realised that owing to various cultural and personal reasons, languages have not been my strengths be it English or Mandarin. As a nation, our language competencies vary significantly. By and large, most of the younger generations are able to communicate effectively in English and a second language with our fellow countrymen. But, with the outside world, special effort have to be made for others to understand our accents especially given our tendencies to speak in a staccato manner and rush through our speech. At times, I received compliments for being able to manage to do a programme in English when that is not being my first language. I do not actually know how to respond to that. Should I clarify with the person? What was the unspoken message behind this statement? Was I being overly sensitive? But for the most part, I behave myself as a GEMM.

I took the opportunity during the reading seminar to speak about this. I think to increase our cultural competency, we need to be able to recognise how prejudices can look like. Outright oppression is often easy to pick out and spoken against. The bias in comments or actions influenced by stereotypes are often subtle and unintentional. Perhaps things like microaggression could be more widely discussed in our work. Living in a society where norms are shaped by the majority can have a bearing on a minority's thoughts, feelings, behaviour, identity and eventually mental health. My personal experiences had made me a lot more aware of these possibilities.

I meet quite a lot of migrant families in my course of practice. Being a minority myself in London now, I thought that this has been an important learning point for me to know what it can possibly mean to be a minority. At the same time, this experience makes me conscious of my majority privilege back home and I do not think I can look at some things the same way anymore. There have been too many examples that I had taken things for granted such as buying lunch from a stall owner who can only speak Mandarin. Retrospectively, these were moments of daily lives which might not had not been things easy for my non-Chinese Singaporeans.

[January 2016] Power in the wider context

[08.01.2016]

I have started to take on more cases on my own at placement. I discovered that I am experiencing some power issues with my co-workers at the placement.

On my previous conversations with my supervisor, I understand that the Diamond and Diamond’s model was one that the service had adopted where they have separate therapists who will work with the adolescent and parents separately exclusively. Inputs between the therapists would be exchanged during case discussions. I did not understand how that decision was made as I was of the view that systemic family work would ideally bring the family together at some point in time instead of working with them separately.

When I explored the idea of bringing the child and parents together at some point in time to one of the practitioners, it was dismissed with the reason that it was not the intent of the referral and the adolescent was not in favour of it.

I found it quite hard to reconcile and had initiated discussing the relevant cases with my supervisor during the next supervision. I think my agenda was really to discuss my difficulties in appreciating the approach although I am unsure how ready I am to be transparent at this moment. I noted the close relationship they have among themselves. The power dynamics between the senior therapists and I, a trainee, come on very strongly here for me.

On one hand, I am recognising that I am not a totally ignorant practitioner who has no clinical experiences. I do have with me years of working with people and have been trained for the first part of the systemic programme. I do not wish to discount my thoughts about helpful practices. Yet, at the same time, I am very junior in terms of systemic work among the practitioners; a trainee in the organisation; a foreigner among them. These power differentials silenced me. I found it hard to be as open as I will like to be. 

[15.01.16]

I spoke to some colleagues at the college to get some advice. With some encouragement from them, I thought I would share my thoughts with my supervisor which I did during supervision.

It was a relief when my supervisor was able to understand my struggles and thought that they were appropriate. She thought that this could be owing to some personal bereavement that the other professional was going through. That helped to put things into context and I was feeling guilty for jumping into conclusions. Nonetheless, my supervisor was very encouraging and indicated that we should have a case conference with the other colleague.

Thus far, the experiences of working with in-house professionals from multiple disciplines have been an eye-opening experience punctuated with challenging moments. Nonetheless, it has been a very enriching process. Being able to check on my personal bias and finding our common grounds and language have proven to be helpful so far. After all, systemic work calls for us to pay attention to the context and this is currently the context that I am in. 

[December 2015] Confusion

Deflated

With the lessons at the University, placements and supervision groups going on concurrently, I am starting to experience the pressure from it all. On a full week, I am seeing clients from Monday to Thursday with lessons in between. The amount of processing that needs to take place is compounded by the sheer load that I need to get my hands on.

While seeing clients have always energised me previously whenever I felt overwhelmed with work, it is different now that I am under training.

In comparison to previous years, the opportunities to practice have increased significantly. Having three different supervisors who are helping me to progress as a family therapist, I feel conflicted at times. I have definitely benefited from the multiple perspectives that I have been able to gather from the different expertise. At times, these inputs may differ and in the extreme situation, contradict. With all these happening on different days of the week, it had impacted on how I see myself as a family therapy practitioner. With the load that I am having, I found it hard at times to have the space and time to sit and process all of these.

It did not helped that I am experiencing some personal difficulties currently which challenged my self-identity and am attempting to seek professional help for it.

I found myself performing differently in different settings. Quite naturally, I think I tend to perform better at settings where I feel more confident and relaxed. It got me reflected on my need to be affirmed by others and how when that does not come, it affected me.

I do not know if this is because of the happenings in my life currently. I am looking forward to having the Christmas break so that I can have some time and space to process all of these. 

[November 2015] When Personal meets Professional

We had a new referral at the clinic and were discussing who should pick up the case.

The parents were said to while accepting of their daughter being a lesbian years ago, were totally thrown off-guarded when their daughter wanted to come out as a transgender now. They were referred for family therapy to help the family managed their differences which had since led into frequent arguments between the parents and the child.

As a trainee new in the supervision group, I was ready to jump into action and get some clients of my own. However, the reason for the referral stopped me from offering to take the case. I pondered over it for a while and decided to speak to my supervisor about my dilemma.

I am a woman who identify as gay. At the same time, I adopt a masculine appearance. Not because I identify as a male (hence, a transgender), but simply a matter of preference and comfort. I was unsure if this glaring appearance would be an issue in working with this family who was having difficulty accepting their daughter's disclosure. If I do pick up this case, should I even share my concerns with the parents? Is this me being paranoid or is this concern valid? I processed this with my supervisor briefly and we thought that I would give the case a go. The parents did not return after the first session. Why exactly, I will possibly never know. But this had me reflected on this bit of my identity.

In my eight years of work with clients in Singapore, I had met two clients who sought therapy because of their identification as a lesbian and was facing family resistance and no client who had identified as a transgender. In my last two months of practice so far, I had encountered 4 families who have a child who identified as gay and this recent case, a transgender. I did not have to think much about which aspect of me was I bringing into the therapy room back in Singapore since it was hardly of direct relevance to the clients I was seeing. But now, there seems to be this need.

There is something about this case which prompted me to be more mindful than usual. It is not about my sexual orientation or sexual identity. It has to do with what I think how I look means to the family and subsequently their relationship with me, therapy and eventually their daughter.

I do not generally subscribe to the belief that we match therapist and clients based on factors such as ethnicity, cultures, life stages, life experiences etc, to increase the therapeutic alliance. However, I am unsure if I still think likewise when the therapist is a representation of the issue the family is trying to work against. While I do not identify as a transgender, I feel irrationally accountable because of the way I dress. I did not want the parents to walk into the session and started to have inner dialogues going, "Oh.. she's one of them", "She is going to be on our daughter's side" etc. While I am happy to discuss it with the parents if it is a concern they want to bring up, I am more hesitant to bring it up especially during the first session if nothing is mentioned by the family.

I am quite certain that I can accept it if the family rejects me. However, my irrational fear is more concerned about if the family rejects not just me but family therapy, have I taken the opportunity of receiving help for the family indirectly. I also feel responsible for the way I conduct myself in the session way more than usual. It is this thinking that I do not just represent my profession but I also am a visual representation of a transgender. 

The time in the supervision group is limited. Hence, we had not have enough time to explore this. Not having to address this identity of mine in my work previously had not given me the space to think about my beliefs and responses. With the potential number of clients I may have to see who identify themselves as gay or transgender, it is probable time for me to give this more thoughts. 

[October 2015] Slow Start

It has been a relatively slow month which gives me a little more bandwidth to think about organising myself for the year ahead.

So far, the allocation of clinics for the year seems to be rather relevant to both the needs of the organisation back home and my personal interests; adolescents (self-harm) and couple. While I had worked with both populations quite a bit in my course of work, the presenting issues, self-harm and mental health, are new areas for me. This is also the first medical setting that I'm practising in. Been doing some readings to understand the backdrop of these settings; policies, NICE guidelines etc. At the same time, I am hoping not to let the medical context dominates my work with the clients.

Working with a family whose presenting issue was a medical condition seemed to added a different dimension to my work. At my previous placement at the social care, the link between the presenting issue (child welfare concerns) and the reason for referral to family therapy was easier to draw. But at CAMHS, the linkage was not as direct most of the time and I thought care has to be put into seeing that parents were not blamed for causing their child to have mental health concerns.

Saw my first family at CAMHS on Monday. It has been a while that I last seen any client. Fumbled a little but overall, it went ok. Although I had worked with reflecting team previously, this was the first time I was working with a screen and with all team members trained in systemic work. The experience was quite new for both the family and me I suppose. The young person preferred for the reflecting team to be in the room instead of behind the screen. Nonetheless, it appeared that after we settled into our conversation, the team's presence faded into the background.

It is probable too early to say much about what it is like to be working in a medical setting. Shall keep an open mind about things!

[September 2015] Here we go again

I thought it just made sense for me to continue my reflective diary on the blog space I had used for last year. This space shall be the place where all my thoughts stemming from my learning of systemic work gather. There is something "permanent" about leaving things on the Internet. I had looked through the entries from the previous year before starting this entry. The previous year seemed to have passed so quickly although it sure did not felt so when I was going through it. Having return for the second half of the training, I hope to anchor my learning from last year and hone my skills more through the extensive practice opportunities in this year.

This return is one filled with lots of mixed feelings. There have been a lot of changes in my personal and professional life since the end of the graduate certificate programme to the commencement of this master programme.

The current group seems to be quite different in composition from the previous group of mates from last year. There is no male in this group. I am the only International student whereas there were three of us from Asian last year. The average age is higher this year which also means the average years of practice among colleagues were way more than our average last year. We have a colleague who is on mobility aid to help her move around this year.

I am excited about the dynamic that would take place with the current cohort. I think the group is likely to bring on a different dimension to my learning given the range of differences from last year.

If the first two weeks were anything to go by, it appears that this is going to be a really hectic year packed with long days of learning and practice. Looks like time management is going to be crucial here.

No time to waste time!