[July 2016] Whose Problem Is It Again?

I had learnt so much from this young person. I think it is only fair that she has a mention in my work. You know those moments where you thought you know certain things and you realise you actually had not when you truly experience what it means? This is one of those moments.

When it comes to problem definition, I had bought into the philosophy of clients defining their problems. To be able to engage clients and support them in their challenges, it has to be a situation where they thought seeking therapy may help them address. I thought I understood how this works until I met this 15 years old.

We met. It was clear from the onset what she thought the family difficulties, or at least, part of it, were. She had a “lazy mum” who she felt had not taken up any responsibility at home yet constantly complained that she was so busy with stuff. A typical interaction will have Mum shouting to one of her four daughters (aged 19, 17, 15 and 14), very often, Client (in her words, she was the only one who would be bothered with her), to bring her a cup of tea. This does not matter when Mum was 10 steps away from the kitchen and Client was upstairs in her room. While Client and the Nan would be busy at the store front, Mum would be at the back playing games on the computer. The children were generally responsible for taking care of the house from cooking to cleaning. They have a roster to work with. Mum’s reason was she has chronic fatigue syndrome but Client said that was never diagnosed. That had created a lot of conflicts among them. Earlier this year, Client was referred to me after a self-harm episode which was triggered by an argument at home with her eldest sister and Nan over misplaced items.

My initial hypothesis back then was that there were conflicts between the parental and child subsystem and some negotiations would be helpful. With that and adding a little dose of collaboration, my plan was to explore with Mum what narratives she had being a mother in her contexts and possibly look at doing some restructuring work. The recommended plan was to have a mixture of individual and family work so that Client has a space to discuss some of her concerns that she had not been able to do so in front of her family. The individual sessions took flight. But not the family sessions. Plans to arrange for that did not worked out. As I was planning with the Client on the family session, getting her ready for that, she told me while she thought it would be good for her family members to hear each other out, she did not think they would be receptive. She foresees them being all defensive. She said they generally do not like to be told they were in the wrong. Although that was not my intent, but I saw the reluctance in the young person and did not pushed on also partially in consideration that she had been feeling better interacting with her family members. We continued our individual work.

Along the way, I never gave up on checking in on the family relationships. There were ups and downs. Initially more downs and subsequently more ups. Things appear much better at home. Client was also moving from having regular to no further self-harm thoughts in the past 6 months. Relationships among the sisters were great with them attending concerts and tours. Occasional bickerings but nothing that threw Client off tangent. She was also coping better with her peer relationships although there were still difficulties and she had plans for her future. Mum, is still being described as the lazy Mum. Occasionally, she tried going to do grocery shopping, but she often got the food she liked (microwavable food) but the children hated. The girls took over the kitchen. Cooked food was served when one of the sisters was at home. Else, Mum would prepare microwavable food unless one of the other girls decided to cook. The 19 years old sister started bringing them including Mum out for holidays, concerts and movies. On her pay cheque which also pays her college fee. The youngest sister started to clear up after herself, when she was in a good mood. Client continued to be the gel among everyone and run errands for the family. The family overall was happier. Still having arguments here and there. But overall, better. Was it my intervention with the family? Of course not! I think my work with the Client while keeping an eye on what was going on in the family allowed us to think about who else was in the family and how through Client’s perseverance and continuous engagement with her sisters, they managed to work around Mum. She told me in jest that Nan had given up on Mum from a young age. Mum had the neighbour panicked and told the parents that the house had been burgled when she saw the mess it was in after Mum accidentally left the house door opened. Mum’s parents told the neighbour, it was not. Client had not given up loving her Mum. She just given up having her Mum changed this bit of her. Together with her sisters, they had created a much harmonious life for themselves at home. Is this an ideal family from the textbook? No. But is this good enough for this young lady? Yes. In fact, I thought that if I had insisted on family therapy and bring everyone in, I am not confident if this is a place that we would be at today. She showed me how there are many ways to work with families.

As part of our review/ending work, I invited Client to help me write up a review report for her. A mocked activity that I thought would help consolidate all the progress and boost the confidence of this young lady to handle things outside of therapy (which was another area relating to ending that we had worked on). With her permission, I have included a copy in this month’s entry.

For that, thank you, Louise*.

[Name has been changed to protect confidentiality of client.]

[Jun 2016] Social GGRRAAACCEEESSS

I have always been someone who try to be mindful and sensitive to differences. But I think coming from a majority race in Singapore and having a generally homogeneous population (in comparison to London!), my worldview has been restricted. Ever since acquainting myself with London and Systemic Work, I see this view expanding, at the same time, I found myself ironically being more intolerance towards people with different (and perceived as prejudiced by me) views.

In the course of practice here, I found myself getting to appreciate a lot more the power of contexts and how different factors could have a bearing on one's life. Notwithstanding its critique, Social GGRRAAACCEEESSS somewhat had weaved itself into my life. In my professional life, I used that to be mindful of power differences and what that could mean for the clients I am seeing. In my personal life, I found myself subconsciously became more vocal about prejudices and discrimination. On a personal social media level, from sharing more of my personal trivial day to day happenings, I started clicking the share button to these days, I go into paragraphs relating my thoughts about the issues. On group chats with friends from back home, I found myself being less reserved about stating my mind and disagreeing with them when they say things which I thought was offensive.

I guess this increase in speaking up is a direct consequence of seeing how contexts had led to power differences and often, prejudices, if not, discrimination. Some of which were really nasty. While I think I remain open to people having different views on things, I no longer am able to remain silent as frequently as before when these differences were used to attack others. I found myself being more agitated as compared to before but at this moment, I am not apologetic for it. The lack of it previously had me kept quiet when I witnessed an act of prejudice even though I did not feel comfortable. Perhaps, the young people I had seen over the year gave me the courage to give a voice to my discomfort. Having seen so many of them having to put up with school bullying and how often, people around them let things slip makes me angry. And guilty. For I realised that I had been one of those who kept quiet when someone else was being bullied for who they are in terms of gender, ethnic, appearance, sexuality, etc. I do not as I settle into this new side of me more, will I have a different approach of expressing myself? For now, I will do it in my little way with people around me.

Xenophobic experiences by foreign workers in Singapore.

A case of child got killed in Taiwan and the Internet was
filled with negativity comments including threats
towards the perpetrator who was suffering from mental health.

How appearance matters

Majority privileges

[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.