[May 2016] Problems for Therapy, Problems in Life

Recently, a couple of cases got me thinking about what made a good outcome of therapy and how when not careful, what seems like a good therapeutic alliance can be impeding progression.

There had been two particular cases which shared similar themes for the past months. I had worked with them for a couple of months and it had come to a point in time that I thought it was time to end the therapy. However, I noted that the clients involved were resistant towards the ending and started to bring in new materials for our sessions. It took me a couple of sessions before noting that they did not seemed to have real difficulties managing those situations. Upon exploration with them, it came through that they did not think they were quite ready to deal with life without therapy. The sessions had somewhat both directly and indirectly created some sense of safety for these young people at a time that they were scared of themselves. They were afraid that without therapy, they might slip back into hurting themselves again and possibly taking it further.

On one hand, I have to admit that it felt good that the young person thought therapy had been helpful or at least they saw it as a critical bit of their lives. However, this just did not sound right; both professionally and personally. If therapy was to be effective, I should be seeing my young person not only being able to move away from self-harm behaviour but to better coping mechanism when they are faced with future issues. I read recently about the original Milan's team's differentiation between psychiatric problems and life problems. It resonated with me. We all face problems in life, but not all of them require therapy. It dawned upon me that my young clients were afraid of facing problems in life. And as they are on their road to recovery, their run-ins with situations in their daily lives made them uncertain if they were ready to deal with life without therapy. 

I shared this thought with the two clients and they agreed that no amount of therapy was going to take away all the problems in life. They recognised that they had made progression and while they think they might be able to handle things to come, they thought having a therapist with them just made things a lot more secure. We agreed to have a couple more sessions to consolidate their achievements, strengths and resources so that they feel more confident as they embark on lives without therapy. 

[July 2016] Note to self: If only I read Glenda Fredman and Caroline's paper on Ending earlier!]

[April 2016] Taking responsibility for my learning

I contemplated if I should include this as part of my reflective diary. I thought I shall as I saw this as a significant part of my learning journey.

I hesitated because this reflection piece has to do with my experience with a supervisor from the supervision group. I was unsure if it would be appropriate but I had decided to proceed as I was clear that writing this served as a documentation of my own learning with no intention to highlight anybody.

For the past few months, I noted a change in me during one of the supervision groups. I started to be more careful in my sharing and less confident in my practice. It was a different me on whenever I attended this group. I thought about it and started to attribute this to my perceived relationship with my supervisor of this group.

I noted that it all started when I felt that I must had fumbled so badly during one of my earlier sessions that my supervisor had knocked on the door several times to ask me to explore a certain direction. That shook my confidence briefly and it did not helped that the family did not returned (at no fault of anyone other than family therapy was possibly not the best option for the family at that moment). I also found myself on several other occasions thinking that my comments during pre and post sessions had been misinterpreted. However, owing to time constraints of having to get ready for the next session, the segment often closed off with me feeling misunderstood. I started to notice that I would refrain from making comments unless asked. Gradually, I was doing more of what I thought my supervisor would want me to do than what I thought I would like to explore with the families. I felt that my wings were clipped yet I was fully aware that this was primarily a consequence of my own perceptions of what was going on and possibly a misalignment of our supervision styles.

This went on for slightly more than a month. I knew it was not personal but there were moments where emotions got the better of me and felt lousy about it. I had initially brushed it off with lots of rationalization. However, after some processing, I thought that I still have another 6 months to go. If I was to ignore this, it would not do justice to my learning and I did not believe that this was not something that we could not resolved. I had decided to approach my supervisor for a conversation after some serious pondering and consultation with a trusted mate.

My supervisor and I spoke about it. I felt that it was one of the best decisions I had made towards my learning here. We managed to clarify some of my thoughts and process some of my emotions. I also got to obtain a better understanding of my supervisor's supervision style and shared how I thought I learnt best. Together, we discussed how we could work together in consideration of our respective teaching/learning needs. It was not a very comfortable conversation as I had not been particularly vocal towards authorities and with the experiences of my comments being misunderstood during our previous interactions, I was not sure if it would happened this time round. But I think, we both sailed through this. I was grateful towards my supervisor for the openness to listen and discuss. With this conversation and our thoughts regarding what else we could do to facilitate our supervision process, I left the room feeling relieved; uncertain how things would be like going forward but certain that this was something my supervisor and I were committed to work out. I knew I could approach my supervisor for further conversations should the need arise.

Trusting the process.

[Update: August 2016]
I thought I should update this entry. It has been five months that we had the conversation. I remained convinced that the conversation was one of the best decisions I had made towards my learning. Notwithstanding the initial couple of weeks of maneuvering and finding a way to regain my confidence, things took flight thereafter. I could find myself feeling free to explore and experiment yet supported by a safe pair of hands at the same time. I think it paid off in my work subsequently.

If you happen to be reading this right now, I will like to sincerely thank you for everything that you had done; being open to listen to me and supported me when I was struggling to scale the next level in my learning. Thank you.

[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.