[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!

[June] Ending / Beginning

Everything just seemed so yesterday. In just nine months, we concluded what was deemed as a two years part time training in foundation family therapy. Everything was intense in these nine months! To exaggerate, I do feel like a newborn!

Thinking back, I started this programme wondering if I made the right choice in choosing this programme to further my professional development; having to leave home and everything that I was having back there.

Took some read to re-read the writings from the past few months. Found many entries to be very much tied to my sense of identity; both professional and personal. I felt that while there was definite areas I could have done better, I have achieved much in these nine months.

Professionally, I felt that the systemic lens is something which has pretty much been implanted in me. Perhaps not a very clear and sturdy one currently, but it definitely changed the way I see things around me. The techniques I have acquired of course required much polishing. But the experiences at the placement had allowed me to develop these competencies under guidance. A rare opportunity that I hardly doubt I will be able to achieve if I had stayed at home.

The training I had at King's had also made me grown as a person. Self-reflexivity is no longer a skill I used for my work. It is basically impossible in my perspective to see myself exclusively in professional and personal self. Very much like Carl Roger's principle on congruence, I find that I was able to appreciate who I am a lot more. Paradoxically, I thought when I stop trying to act professionally, I became more professional or rather, ethical.

Outside Portacabin, home of family therapy department

Outside the IoPPN where we spent a good nine months together

One major gain that I had which I had actually wrote very little, if any, about, is the peer support I have within the programme. I felt that they deserved special mentions as I highly suspect that my experiences in the programme will be different if they have not been who they are. Every single one of them. Given that we spent three days each week in the classroom exchanging ideas and thoughts, the level of trust and comfort in the group is so critical for us to be vulnerability in front of each other. To be able to discuss difficult viewpoints, display our unpolished skills, take constructive feedback be them negative or positive, I find these qualities extremely crucial for me to achieve what I have achieved thus far. For that, I count my blessings.

Sometime last month, I received the conditional offer for the MSc progamme. I guess my journey (of course pending the result of my current programme) in family therapy training has not ended. I wonder what I will write in my first entry next year if I do get into it. For now, I consider myself as completing a lap of training but definitely not done. This ending is also going to be the start of my next lap.

[May] Fluency vs Complacence

Quote for Self-reflexivity Exercise

As part of my learning, I had asked to be given the opportunities to be attached to different clinicians so that I can get to experience different styles and learn from a broader pool of experiences. My supervisor had kindly arranged for that. In fact, I was fortunate enough to be put into a family therapy clinic and co-managed cases with 2 different therapists.

While the initial phase was filled with anxieties and excitement, I started to find myself getting somewhat uncomfortable with some of the practices from other practitioners. I do not know whether it was because I became more familiar and increasingly fluent with the different models and practices to be able to offer some critiques or have I simply become too complacent and in fact transfixed on how things should be done that I am less tolerance to differences. Either way, I did not share these thoughts openly with the practitioners involved. I did however trusted my supervisor to share briefly although it was not without apprehension as she was their supervisor as well.

I still believe that I had learnt a lot from them within the sessions. However, as I find myself getting more comfortable in the collaborative approach of working with clients and more familiar with conversations on power, I started to shift uneasily at times during some of the sessions with my co-therapists. In fact, there was once that I had to stop myself from interjecting into a conversation between the co-therapist and the client when I found them engaging in a power struggle. The client had expressed her thoughts about the therapy and the co-therapist, I thought, had taken offence and tried to defend herself and correct the client's perspectives. At a point in time, I thought there was some passive aggressive manner where the co-therapist indicated that she was there upon the referral of the social worker working with the family and if the client is not interested in the sessions, she would not be able to do what she was told to do and had to convey the information to the social worker accordingly.

Extending into my understanding and appreciation of key ideas about engagement such as joining, exploring client's perspectives of her concerns and invitation to dialogues, I thought the situation could be better handled. After the session, we had our debriefing. When I tried to explore the intent of the therapist (just in case it was a strategy which I was unaware of), I faced some resistance. In fact, as I reflected back, I remembered her crossing her arms and I backing off in my seat. While there was no hard feeling thereafter, I knew that I had been mindful of the power differentiation between us (qualified therapist vs trainee; employee vs trainee; local vs student; both of us under the same supervisor) and had chose not to articulate my thoughts in a bid to maintain peace.

Reflecting back, I wonder as I develop myself in this area of work, have I also end up like some of the therapists who often defend their theoretical inclination against others simply because of their loyalty to certain ideas and they reject those they do not agree with. I do not want to be a therapist who is not opened to differences but neither do I want to be a therapist who is so reluctant to voice my concerns when I think the situation may not be helpful to the work with the clients. The idea of social constructionism just came to mind. What is helpful and what is not? What is appropriate and what is not? Who defines them?

[April] The larger system

Another day at the placement. It was a tiring and long day. Had three sessions today. I think the most challenging bit of it was the digesting of how my hands are tied as a family therapist trainee.

I had been informed over the past two weeks that a couple of my cases will be transferring out from me to the family support team as they do not present any further safeguarding concerns. This will take effect in the next two to three weeks.

While I can understand the decision from the perspectives of the department and social work unit's perspectives, I still struggled with the situations. 

I do not fully understand the connection between the family support unit and the child protection unit. I came to realise that I was not the only one. It appeared that several practitioners in the department are not totally aware of the work done by the family support unit as well. This was somewhat appalling to me given the systemic nature of work that Hackney was to be known for. From my perspective, it will be important for the key functions of the teams to be known across the practitioners especially when we are the ones making the recommendations to the other unit. I was surprised that the responses I had from several individuals were they were not too sure what would the unit be doing exactly. I cannot help but think if this is indeed client centric.

Lots of what happened today made me questioned on how client centric the work that I had been doing has been. 

I had a few cases which required me to conduct an assessment on the family relationships and dynamics, their need and potential for further work under the purview of the social care. 

I understand that if the case does not pose any safekeeping concerns, it is unfair to keep the family under social care instead of providing them community support. However, I found it hard that after we had established rapport with them and had started to explore certain deep rooted issues, we had to inform the family that the case has to be transferred out to another unit. I am definitely coping with my own loss with regards to the aburpt disruption to the therapeutic work. I cannot help but think what does it mean for the clients who took time to connect with the therapist and open up only to be told that they have to redo this with another caseworker. 

It definitely did not helped when the practitioners working with me on the cases told me that this was how things worked here. They were caught off handed as well but did not think there was anything else they can do about it. Perhaps given my social worker's background and personality, I found that quite an unacceptable reason. While I understand that there are rules and a larger system that we all operate within, I hate to think that we are subjected to rules which are not necessary helpful and can in fact bring harm to the very people we are out to serve.

I thought that better communication can at least take place between the two subsystems to ensure that both parties know how the work will look like in order to best prepare for the transition; be it a case transfer or closure. A conversation on the timeline and the expected work needed sure does not sound too difficult a task to me.

[Post-script: I had brought up my thoughts with my supervisor and she had raised the concerns with the head of department. I was really glad that the viewpoints were concurred by the head and she had indicated that the welfare of the clients should be the priority over protocols. When deemed necessary, the clinical team should be allowed to request for an extension to conduct some ending work with families. That was definitely a relief to me. While it might be too late for some of the cases I had on hand, I did manage to secure an extension for one case which I thought will benefit from at least one to two more sessions to place a good punctuation to our work thus far. On the other hand, I cannot help but wonder what if someone had raised this concern in protocols up earlier?]

[March] Growth

I felt that this month was a month of rollercoaster. The month started really poorly where I constantly felt that I did not know what I was doing during my sessions with clients and highly doubted myself. It did not helped that I found myself constantly returning to the conversation I had with the seasoned practitioner at placement last month. I am so close to the deadline of the application of the MSc programme that I really did not know if I should go for it.

Thankfully, while all these are happening, I managed to speak to several people who put me in the right place.

Made an appointment to meet Petra. She had been really encouraging and helpful in helping me process my emotions and lack of confidence. Among all, she sent me an article about my sense of feeling deskilled. It was a good read and I will include this in the portfolio. I felt so much more at ease; knowing that I am not alone in this experience. First hand experience in normalizing!

On top of that, the seasoned practitioner whom I spoke to also sat me down one of the days and said that he went back and thought about my questions to him. He drafted up a piece of reflections and wanted to share with me. I was extremely grateful to that. With this permission, I am reproducing it in my portfolio.

For some reasons, after these conversations, and some positive experiences both in the classroom and sessions, I felt way better about myself. I realized that this is possibly what others called growth. And isn't that what I am here for exactly!

To end of this month, I had finally put in my application for the MSc programme.