The Influence of Culture on the Practice of Professional Counselling

Preamble

Culture is the core of internal ways in which human beings develop their sense of self, including values, beliefs, thought patterns, perceptions, and worldviews. All these qualities help determine and shape one’s external culture - the ways in which one establishes and maintains a relationship with the environment and others through implicit norms, language, traditions, rituals, and loyalties that influence attitudes, behaviors, and customs (Gushue, 1993). While it is true that Singapore is a mix of different ethnic groups, each group has retained much of its individual unique cultural character. This is because Singapore’s policy has always been geared towards multiculturalism, where every ethnic group is allowed to preserve its own culture while peacefully interacting with others. In the light of this, counselling and intervention is always presented within the cultural context and constraints inherent in our cosmopolitan society. The understanding of a client’s unique culture is necessary in order for a counsellor to effectively help the former behave and feel differently in a trusting relationship so as to achieve their goals.

This paper is a qualitative inquiry by the research group to explore the impact of culture during our training as counsellors. The following discussion includes our views on the importance of cultural influence in our counselling work, our personal values, prejudices and motives for helping people as well as our worldviews as a major ethnic group. As we identify various cultural issues encountered when applying western counselling models in the Singaporean context, our constructivist’s approach would be to unlearn our negative cultural conditioning, and re-construct and adopt more meaningful models. The benefits of a multicultural perspective would be examined and ideas on ways to acquire greater multicultural counselling competency would be presented.

Methodology

In the social sciences, qualitative research is often a broad term describing an in-depth research that focuses on how individuals and groups understand the world and construct meaning out of their experiences and the reasons that govern it. The why and how of decision-making will be investigated. It is essentially narrative-oriented and uses the methods of content analysis. The researchers are explicitly a part of the data gathering process. The need is for smaller but focused samples to make meaning of culture in their counselling practice. (Retrieved from http://en.wikipedia.org/wiki/Qualitative_research#References on 12th September, 2006.)

Our group of six members met once before the workshop to make sense of the research project handouts we received earlier. During the workshop, we formulated a questionnaire (included as Appendix A) to be responded individually by members of the group. At subsequent meetings, we presented our individual responses (data) in transcripts. The process of open coding, axial coding and selective coding (Neuman, 1997) were adopted.

In open coding, the individuals’ transcripts were scrutinized for common and salient points. They were highlighted using colored code labels for themes that emerged. For axial coding, connections between categories and sub-categories of the earlier coded themes were derived. In so doing, we expanded our knowledge of the categories and identified the axis of key concepts. Finally, in selective coding, we revisited the data and earlier codes to analyze and elicit further evidence to validate and support the major themes.


Key Dimensions of the Group


Gender M F F F F F
Age 53 53 45 37 30 48
Race Chinese Chinese Chinese Chinese Chinese Chinese
Religion F/Thinker X'tian X'tian Catholic X'tian X'tian
M/Status Married Divorced Married Married Single Married
Academic MBA BSc (Hons) Diploma BBA BSc Diploma
OccupationManagerAdministratorRealtorDirectorProgram ExecutiveCourt Volunteer
(Figure 1)

As can be seen in (Figure 1), our group is quite homogenous with similar demographic profile. All are of Chinese decent; therefore belongs to the dominant ethnic group in Singapore. Majority are Christians, professional and bilingual, i.e., English and Mandarin speaking. Age and academic qualification are the prominent diversities in the group. By and large we share similar cultural heritage in the Chinese community.

Participants’ Perspectives

There is a group consensus that culture is an important component of counselling as Magdalene puts it:
Culture moulds one’s identity which is expressed in terms of core belief, value system and thought processes. The ability of the counsellor to connect with the client at his core beliefs, value and thought processes would determine the level of bonding in this helping relationship. The counsellor’s level of sensitivity towards the client’s cultural identity has an impact on the counselling process and its success thereafter.

According to Juliet:
In diagnosis, psychological judgments are never free from the influence of therapist’s own cultural values. In intervention, counsellors need to be knowledgeable of the culture of their clients because each culture holds different ideas about what constitutes problems in living.

As we have grown up in a cosmopolitan environment, we are immersed in various orientations of different ethnic groups. Our awareness of our own culture only increases when we go to places where our culture is not the norm. Similarly in a counselling room, when we are with our client from a different culture, our awareness of our own culture tends to increase too. We are aware too of the diversity existing within the same culture as people may communicate and interact in a whole range of ways.

Our worldviews as ethnic majority are highly correlated with cultural upbringing and life experiences. There is a tendency to take for granted that the ethnic minority has full knowledge of our culture since it is pervasive in the society. On the other hand, some of us harbor tinted views of the ethnic minority that cause us to unwittingly impose upon them stereotypes and preconceived notions. Annie shared her notion: ‘It is typical of Indian men to drink and abuse their spouses.’

Jennifer shared on what being sensitive to ethnic differences entails:
My sensitivity includes respect and acceptance of who they are, the way they are and their beliefs. I choose to treat people of the minority race fairly and equally. I do not feel the need to treat them with sympathy; otherwise, it would only remind them that they are being differentiated. I learned from my Indian and Malay friends at school about their feelings as minority races in Singapore and that they prefer to be seen as equals.

To be more effective counsellors, we have to first examine ourselves or be aware of our personal values, beliefs, prejudices and motives for helping people. For instance, Peter’s own cultural beliefs that men should be stronger and be able to take on the world and solve their problems rationally and efficiently make him more sympathetic toward his female clients. While some of us in the group who are Christians may be motivated by the teaching of Christ and our spiritual conviction to help people, Peter has this to say, ‘My motives for helping people is firstly for some sort of spiritual maturation. It is my way of building a better world for the future.’

On the whole, there is a recognizable appreciation of our own culture in our group. The curiosity to explore the deeper meaning of our own cultural behavior will certainly enlighten and make us more sensitive to the differences or similarities existing in different cultural groups. ‘A wise counsellor would always try to transcend such barriers and enter into the frame of reference of his client and operate from there.’ (Yeo, 1993)

The first theme that emerged was therefore
the need to be self-aware
as we approach clients from different cultures.

Common Cultural Challenges

The clients we see include students from as young as 6 years old, elderly patients at Nursing Homes/hospital. We also have couples with marital, family and financial issues. Their age group ranges from early 20s to the 70s. They are a mix of Singaporean Chinese, Malay, Indian and some immigrants. Our clients are mainly from low to average income group with basic education. English and Mandarin are the main languages used. Dialects are used when counselling the elderly folks.

Each member in the group shared both common and unique cultural issues they face in counselling. The sexism issue Annie regularly encounters involves female victims of domestic violence in Indian family whose men predominate in positions of power. Most oppressed Indian women inevitably choose not to react for fear of being ostracized by their own family and community. According to Yeo (1989), Asian derives their identity from membership in a family and a community and focusing on the individual might well alienate the person from the family.

Peter and Juliet shared about the common gender issue where parents think they must stay with sons only, while conflicts with daughters-in-law are common issues too. Some parents choose to stay on their own to avoid humiliating their sons. Medical and emotional problems may result from loneliness, poor self care and diet.

Jennifer related her early experience:
I’ve encountered difficulties on many occasions with clients of a different race, particularly Malay clients, in dealing with issues on pregnancy crisis. My early impression was that they were either not willing to share nor receptive to explore other options and alternatives pertaining to their decision to terminate their pregnancy. The session became more fruitful only after I acquired greater understanding of the Malay culture.

For Magdalene, while she is competent in conversational skills with some dialects, attempting to apply counselling techniques or skills present a real challenge. Majority of the counselling approaches are western in origin. The concepts and explanation are all in English. It is easy to miss the deeper nuances when she attempts to apply or translate them into dialect or language which she is not fully competent in.

Both Magdalene and Ruth observed that it is culturally the norm of the older generation to attribute crisis to some external causes and to seek help from temple mediums. The words of the mediums will then be accepted as truth. It can be a real challenge to counsellors from a different faith.

Ruth, the youngest member in our group, perceives age as a stumbling block to effective counselling when her clients are much older. In the Asian context, age is a sign of maturity and wisdom. With elderly clients, we are expected to show respect and humility, not as someone to solve their problems.

Annie faced the social-economic issue when she encountered Singaporean men who resorted to increase their socio-economic status by taking wives from the poorer ASEAN countries. The wives function more as domestic helpers or care providers to the elderly/invalid parents or young nephews and nieces within the extended family. The relationship is further strained by language barrier and other cultural issues.

Western Counselling Models in Singaporean Context

The group is pragmatic in our counselling approach, integrating different therapy models to meet the client’s unique needs. With cross-cultural interaction comes the possibility that the client’s intentions and actions may be misperceived, misinterpreted, and misjudged notably, when we employ the western counselling models on culturally different clients. We are aware that some of these models may not even fit people from western cultures due to within-culture diversity and other diversity factors beyond culture. (Egan, 2005)

The second theme that emerged was the need to understand the worldview of culturally different clients in order to know how best to
integrate the western counselling models in our counselling work.

Magdalene commented that the concept of individuation in Bowen Theory is culturally not in tandem with many elderly Chinese clients, who come from an environment where the family, community, or clan takes precedent over self; hence differentiation of self can be alien to them.

A person’s identity is formed and continually influenced by his or her context. Working effectively with clients requires an understanding of how the individual is embedded in the family, which in turn requires an understanding of how the family is affected by its place in a pluralistic culture. (Sue, Ivey & Pedersen, 1996).

Bowen Theory encourages the therapist to look into the Family of Origin to examine the interlocking relationships. This can present itself negatively as in-laws or family members may not be forthcoming when it comes to talking about sensitive and conflicting issues inflicting the family. Juliet presumed Bowen Theory will be better understood and accepted by the English-educated clients, but she found out to her dismay that some concepts contradict their cultural beliefs.

Peter found Rational-Emotive Behavioral Therapy (REBT) to be too confrontational in style. Telling a client that he is “horriblising” and “catastrophising” his life issues when he is seeking understanding from a counsellor in his moments of anxiety is not going to be welcomed. Asians generally seek familial help when they have problems. The concept of going to a counsellor who is a stranger is already a major deviation from their social norms. Facing a challenging counsellor may pose as a humiliating experience for some.

Annie’s observation:
Solution-focused Brief Therapy (SFBT) focuses on what clients want to achieve through therapy rather than on the problem(s) that made them seek help. The approach does not focus on the past, but on the present and future instead. This goes down well with the clients she sees who are pragmatic and time-conscious.

However, Magdalene observed that asking the miracle question to a pragmatic elderly client may pose a challenge. Some of them have mindsets that have been deeply entrenched in their being; they do not see the need to change. Similarly, to challenge the Irrational Beliefs (Cognitive Behavioral Therapy) of the elderly whose sense of self has been conditioned to adopt a resigned disposition can be an uphill task.

The use of `hot-seat’ fantasy technique to help clients express their feelings where there is unfinished business may not be favored by the more ‘conservative and traditional’ clients as unleashing negative emotions towards the deceased is considered a taboo.

Magdalene related her encounter:
Using Gestalt approach, I encouraged him to imagine that the mother was present at the moment, and for him to tell her what was on his mind. He responded, ‘she is already dead, what is there to say?’ I realized later that while he might be bad mouthing and blaming her for his current plight, it was culturally not appropriate for him to confront her.

Ruth felt incompetent when she encountered elderly people who often interrupted her during conversation to correct her. Her age and lack of knowledge in dialects made it difficult for her to express herself aptly. But she found Carl Roger’s Person-Centered therapy useful when working with clients who question her abilities.

Multi-cultural Competencies

The challenges we face as counsellors in a multicultural environment require that we know and understand the client’s culture so as to be congruent with the frame of the world that the client is in during counselling, i.e., individuals are best understood by taking into consideration salient cultural and environmental variables. Regardless of the therapist’s orientation, it is crucial to listen to the clients and determine why they are seeking help and how best to deliver the help that is appropriate for them. (Corey, 1996) In this pluralistic and post-modern age, no one helping approach has all the answers for the clients we see due to the complexity of human beings, as expressed by Sue, Ivey and Pedersen (1996).

The third theme that emerged was the need for therapists to create therapeutic strategies that are congruent with the range of values and behaviours
that are characteristic of a pluralistic society.

Jennifer had this to say:
Without a deeper understanding of the Malay culture and religion, my counselling sessions with the Malays would certainly be unfruitful. There are family and social pressure to learn within the context of religion and culture. The Malay clients who are pregnant out of wedlock find themselves opting for abortion as the only way to avoid violating family tradition. I have to work on interventions that are congruent with the values of the clients.

It is a sign of respect that counsellor refrains from deciding what behaviour should be changed. Through skilful questioning on the counsellor’s part, ethnic minority clients can be helped.

The process of internalizing a new culture is an on-going undertaking. Generally the group is willing to be exposed to all kinds of clients so as to open up our own world views of the different cultures in our society. This includes interacting with people of different races at social events and festive celebrations. We recognized that with the culturally-constraint client we have to go slow during the first counselling session. The clients can be invited to teach the therapists about the significant parts of their cultural identity.

We all acknowledged the importance of supervision and guidance when we are unsure and need clarification. We also will be seen as more professional if we master the basic terminologies of counselling approaches in other languages/dialects.

Having an enquiring and inquisitive mind about the different cultures will help broaden our perspectives. Formal education on the multicultural aspects of counselling will help to hone our skills. We can also gain insights by reading articles and books related to multicultural counselling. There are hefty handbooks offering the theoretical background, practical knowledge, and training strategies needed to achieve multicultural competence. (Pope-Davis, Coleman, Liu, & Toporek, 2004). In addition, there are highly detailed research studies offering further insights in multicultural competence. (Darcy, Lee, & Tracey, 2004). The greater our depth and breadth of knowledge of culturally diverse groups, the more we can be effective practitioners (Corey, 2001).


Conclusion

In summary, the qualitative inquiry has promoted self-awareness of our own personal culture as we develop a sense of the world. Courage, openness and humility are some important elements we identified to secure trust and acceptance by our clients of different cultures. Our group will certainly strive to integrate appropriate counselling approaches to create therapeutic strategies that are congruent with the client’s range of values and behaviours, without abdicating our own deepest beliefs and values.
(2,991 words)


Appendix A

Questionnaire

1. What kinds of people do you see in your practice?

2. What are some common cultural issues that you face in your
counselling?

3. What kinds of issues can you identify in applying western
counselling models in the Singaporean context?

4. What are the difficulties that you find in working with clients
from a different culture? You may illustrate with a case.

5. What are some of the ways you adopt during counselling to effectively
overcome the difficulties you find working with clients mentioned in question 4.

6. How has your multi-cultural perspective benefited you in your
counselling work?

7. What would you do about your training as a counsellor to acquire greater
multicultural counselling competency?
Reference

Gushue, G. V. (1993). Cultural-identity development and family assessment: An

interaction model. The Counselling Psychologist, 21, 487-513.

Neuman, L.W. (1997). Social research methods: Qualitative & quantitative

methods (3rd ed.). Boston: Allyn and Bacon

Yeo, A. (1993). Counselling A problem-solving approach. Sg:Armour

Yeo, A (1989). State of the art: Indigenous/indigenized counselling practices in

Asia. Social Dimension, 1989:2. Singapore: Singapore Association of

Social Workers

Egan, G. (2005). Skilled helping around the world. USA:Globus Printing

Sue, D.W., Ivey, A.E, Pedersen, P.B. (1996). A theory of Multicultural Counselling &

Therapy. U.S.A.: Brooks/Cole.

Corey, G. (1996) Theory & practice of counselling & psycho (5th ed.). Pacific Grove,

CA: Brooks/Cole

Pope-Davis, D. B., Coleman, H.L.K., Liu, W.M., Toporek, R. L. (2004). Handbook of

multicultural competencies in counselling and psychology. Thousand

Oaks, CA:Sage

Darcy, M., Lee, D., Tracey, T.J.G. (2004). Complementary approaches to individual

differences using paired comparisons and multidimensional scaling:

Applications to multicultural counselling competence. Journal of counselling

psychology, 51, 139-150.

Corey, G. (2001). Theory & practice of counselling & psycho (6th ed.). Belmont,

CA:Wardsworth/Thomson Learning.

"Life is not worth living.."

Anxiety & its main symptoms

Unlike the relatively mild, brief anxiety caused by a stressful event such as attending a job interview, anxiety disorders are chronic, relentless, and can grow progressively worse if not treated Anxiety disorders are the most common of emotional disorders, affecting 9.3% of the general population in Singapore, i.e. 1 in every 10 Singaporeans. (Ang, 2006) Each anxiety disorder has its own distinct features, but they are all bound together by the common theme of excessive, irrational fear and dread. (Refer to Appendix A for a list of anxiety disorders.) Anxiety disorders disrupt the daily functioning (social & vocational) of the people.

Anxiety produces physical symptoms such as rapid or irregular heartbeat (palpitations), stomach problems (gnawing feeling, nausea, "butterflies," diarrhea, irritated bowel syndrome), sweating, or feeling cold and clammy, body tension, fatigue or shortness of breath, shaking, & sleep disorders.
Emotional symptoms of anxiety include a general sense of apprehension and dread, nervousness, irritation & fear that you are dying or going crazy.
(http://www.anxiety-guide.com/symptoms-of-anxiety.htm Retrieved on 26 Aug, 2006.)

Depression & its main symptoms

Depression is a medical condition that affects a person’s thoughts and feelings as well as the body. t differs from normal sadness in intensity, duration, and interferes with one’s daily functioning. Depressive disorder is common & highly treatable. It is an internal “stress state.” To an outsider, the symptoms seem to represent a form of either agitation or withdrawal. The symptoms of depression may be inappropriately dismissed as understandable reactions to stress or an attempt to receive attention from others. (Albrecht A.T. & Herrick C, 2006.)

The DSM-IV-TR defines a major depressive episode by the following symptoms: Depressive mood, loss of pleasure or interest, insomnia, agitation/retardation, fatigue, increased sense of worthlessness, decreased concentration & recurrent thoughts of death and suicidal ideation. If these have been experienced for more than two weeks it is essential to seek help. (Chia, 1999) Treatment consists of medications, psychotherapy, cognitive therapy, electro-convulsive therapy or combination of these treatments. With treatment, 80-90% of people with major depression disorder will recover. (http://www.depression-guide.com/symptoms-of-depression.htm Retrieved on 26 Aug, 2006.)

Therapeutic Intervention on Depressive/Suicidal Client

Depression plays a large role in suicide. The warning signs include thoughts or talk of death or suicide, or harm to others; or giving away of prized possessions. When the client says `life is not worth living’(an indirect verbal clue of suicide idea), as a therapist, I have to avoid rushing blindly into the suicidal problem as one of the first things to be assessed. My first priority will be to gain insight into his life by obtaining his medical history and to ascertain if he is presently on any medication, such as anti-depressant. If he is not, I will ask about his current mental & physical state to determine if he is experiencing symptoms of depressions (as stated in the previous paragraph) in the last two weeks. If found to be so, I will explore with client possible reasons for the severe depression, namely:
- A medical condition that is debilitating, painful, or life-threatening;
- physically, emotionally or sexually abused; drugs or alcohol abuse;
- mental illness like schizophrenia or bipolar disorder;
- homosexuality (especially teens) because they feel misunderstood or rejected by their families
- anti-depressant medications can worsen depression or cause the emergence of suicidal thoughts. (http://www.helpguide.org/mental/suicide_prevention.htm Retrieved on 27 August 2006)
- Stressors (examinations, NS training, marital & family conflicts) (Chia, 1999)
- In the west, family, twin & adoption studies have shown that there are genetic factors in suicide involving the transmission of mental illness. (Roy, 1989)
- Shaffer & Gould (1987) believe that one has to consider the effect of imitation or contagion. Fortunately in Singapore, contagious suicide is uncommon. (Chia, 1978)
At some point during session, I will trust my instinct & ask if he is feeling suicidal. I do not think by doing so, I am putting ideas into his head, but instead may bring out a topic that has most likely been thought of already. As a therapist, I have to be prepared to hear suicidal thoughts and feelings & not be frightened by the expression of such wishes. (Chia, 1999) If the client admits he is feeling suicidal, I will acknowledge his feelings of hopelessness & pain. For the client suicide might seem like the way to end the pain since he may have trouble imagining another way to relieve the extreme suffering. This could partially be due to errors of thinking, such as overgeneralization, catastrophic thinking, Jump-to-conclusion or personalization. (Albrecht A.T. & Herrick C, 2006.)
As suicidal people are often afraid that trying to get help may bring them more pain, I will need to show unconditional acceptance & warmth in order to re-establish a sense of hope. If the client is young, he may not be willing to provide reliable feedback nor co-operate with treatment. I will need to be ‘warm, caring & responsive without being familiar.’ (Cantor, 1977)
If the client’s suicidal ideation is motivated by pathological reasons, his lethality level will need to be assessed, and hence hospitalization may be necessary for the protection of the client. However, the benefits of intensive interventions such as hospitalization must be weighed against their possible negative effects (e.g. disruption of employment, financial and other psychosocial stress, and social stigma).
There is neither a reliable & valid screening instrument nor a psychological test which can predict with any degree of accuracy whether a person will commit suicide. (Chia, 1999) Beck’s Suicide Intention Scale (Beck et al., 1974) taken in isolation would be of limited value but in combination with clinical findings, it can be useful. Beck et al (1975) found a person’s subjective expectations about the future (Hopelessness Scale) were highly correlated with the seriousness of his suicidal intention.
More importantly, I will ask
 if client has a plan for suicide. Having a plan means he is that much more serious about intending suicide. (For example, sleeping pills have been collected.)
 if he has a history of prior suicide attempts? The more times a person has already attempted suicide, the greater the risk of succeeding.
 what kind of resources are available to him? (Risk will be higher if client has marital woes, very few relatives and has only one close friend.)
 What are his cultural & religious beliefs relating to death & suicide.
Suicide is a coping mechanism & a form of communication – saying something to someone. Here is where I introduce the concept of Ambiguity as part of the client is oriented toward self-destruction yet another part is strongly life sustaining. (Hipple, Ph.D) Berne (1972)’s inviolable rules of death will be explained to the client at the opportune time, `No parent is allowed to die until all the children are over 18 & no child is allowed to die while either of his parents is still living.” I will ask the client: “Who needs to know… about your pain?” I need to recruit the family and significant others into the intervention as suicide do not exist in a vacuum. “You think that you are a burden to your family, can I talk to your family…?” I need to seek permission to contact client’s social support network so as to forty it. This goal can be accomplished without revealing client’s suicide intent. However, in clinical circumstances in which sharing information is important to maintain the safety of the patient or others, it is permissible and even critical to share such information without the client’s consent. (APA, 2003).
Before ending the session, I will tell the client i care about him and want to help develop contingency plan so that he knows who to contact in time of crisis. I would presume he has not been told that he is important and deserve to stay alive by providing him the permission to live – “I want you to stay alive.” He will be reminded to keep his part of the Stay-Alive contract, i.e. to call me before he does anything to harm himself. (Hipple, Ph.D)
I will encourage him to go on an exercise routine as exercise releases chemicals called endorphins which will lift the mood, make one feel energized and sleep more soundly. I will explore with him the possibility of taking breaks – naps, movies, a short holiday with his family/friends to enhance interpersonal relationship. He will also be told the benefit of journalling his thoughts and feelings.

Summary

Psychotherapies and other psychosocial interventions play an important role in the treatment of individuals with suicidal thoughts. Interpersonal Psychotherapy (IP) and Cognitive Behavior Therapy (CBT) have been found to be effective for the treatment of depressions. The goal of IP is to improve communication skills and self-esteem. Areas of social functioning that may be addressed are interpersonal disputes, role transitions, grief, and interpersonal deficits. CBT may be used to decrease two important risk factors for suicide: hopelessness & suicide attempts. The automatic thoughts and behavior of a self-defeating quality in the client will be focused in order to make him more conscious of them and replace them with more positive thoughts and behaviors. (Albrecht A.T. & Herrick C, 2006.)
I will follow up with the client especially on missed appointments. I will also re-establish the Stay Alive Contract by tightening loopholes in the contract and looking into contingency plans for new stress & crisis. In the stress of the immediate crisis, I may have to be active and directive. If the client is hospitalized, it will be safer to be there for him immediately following hospital discharge, especially if his family members are not available. (Hipple, Ph.D)

Appendix A
List of Anxiety Disorders
Anxiety Disorder Short Description
Obsessive Compulsive Disorder (OCD)

Obsessive-Compulsive Disorder, OCD, is an anxiety disorder and is characterized by recurrent, unwanted thoughts (obsessions) and/or repetitive behaviors (compulsions).

Acute stress disorder
Acute Stress Disorder is a anxiety disorder that develops within one month after a severe traumatic event or experience.

Separation Anxiety Disorder
It is normal for toddlers and preschool children to show a degree of anxiety over real or threatened separation from people to whom they are attached.

Social Anxiety Disorder
Social anxiety disorder is an excessive, persistent fear of social or performance situations.

Phobic Disorders
A phobia is an anxiety disorder in which the affected person experiences an excessive or irrational fear of a specific situation, object or activity that disrupts their ability to function in normal daily activities. Specific Phobia, Social Phobia, Agoraphobia.

Post Traumatic Stress Disorder (PTSD)
Posttraumatic Stress Disorder is a complex health condition that can develop in response to a traumatic experience - a life-threatening or extremely distressing situation that causes a person to feel intense fear, horror or a sense of helplessness.

Panic Disorder (Also see Panic Disorder with Agoraphobia)
The Panic Disorder usually makes the person believe that they are either seriously ill or about to die, and can leave the person feeling distressed or shaken for quite a while afterwards.

Tourette's Syndrome
Tourette Syndrome is an inherited, neurological disorder characterized by repeated and involuntary body movements (tics) and uncontrollable vocal sounds.

Anxiety Due To A Physical Disorder Or A Substance
Due to the direct physiological effects of intoxication or withdrawal from a substance.

Generalized Anxiety Disorder (GAD)
Generalized Anxiety Disorder (GAD) is when persistent worry and anxiety about your health, work, money or family last for at least six months, even when there are no signs of trouble in your life.

(http://www.depression-guide.com/anxiety-disorders.htm Retrieved on 26 Aug, 2006.)

Reference

Ang Y.G. Dr. (2006). Lecture notes on Anxiety.

Albrecht, Ave T. and Henrrick, C. 100 questions & answers about depression. Sudbury, MA: Jones & Bartlett Publishers, Inc.

Chia, B.H. (1999). Too young to die. SG: Times Books International

Roy A. (1989). Genetic & suicidal behaviour. In: Report of the Secretary’s Task Force on Youth Suicide Vol2: Risk factors of youth suicide. Washington, DC: U.S. Government Printing Office.

Shaffer D, Gould M. (1987) A study of completed & attempted suicides in adolescents. Progress Report, Rockville. MD:NIMH

Chia, B.H. (1978). Suicide in Singapore. MD thesis. University of Singapore

Beck AT, Schuyler D, Herman I. (1974). Development of suicide intent scales. In:Beck AT. Resnick HLP, Lettieri DJ,eds. The prediction of suicide. Maryland:Charles Press

Beck AT, Kovacs M, Weissman A. (1975) Hopelessness & suicidal behaviour: An overview. Journal of the American Medical Association.

Berne, E. (1972). What do you say after you say hello? New York:Grove Press

American Psychiatric Association. Practice guideline for the assessment & treatment of patients with suicidal behaviours. Arlington (VA): American Psychiatric Association; 2003, Nov. 117 p.

Hipple, J. Ph.D. Suicide – the preventable tragedy. Adapted from Mr Benson Soh’s note.

Ashweek

SF BRIEF Therapy

Introduction of Henry & Eng

Henry (aged 49) was `shocked’ when his wife, Eng (aged 46) filed for a spousal maintenance order at the Family Court. He felt that he has always been very consistent in providing for the material needs of his wife & 3 children aged 19, 15 & 12 . Henry & Eng are no longer functioning as husband and wife sexually for some 3 years now. They sleep in separate room albeit under the same roof. Henry maintained that their marriage is irreconcilable as they are no longer able to talk to each other calmly. He thinks that Eng is irresponsible and irrational. Occasionally he would issue threat of divorce. Eng is thus plagued by a nagging sense of insecurity. Nevertheless, the couple has opted to stay put for the sake of their children.

Henry focuses on all his three children especially his eldest daughter whom he thinks takes after him in many ways. The youngest son was born pre-matured & a slow learner but the parents are satisfied with his academic progress at this point in time.

Area of Concern

The couple is barely coping with their 2nd child, Ed (aged 15), whom they claimed defiant and out of control. Ed’s obesity became a great concern when he was found to develop breathing difficulty at night when he sleeps. He was placed under a weight control programme at a local hospital. Henry ferries Ed to the doctor for regular medical reviews. Ed is perceived to be addicted to the computer games and the school is after his parents for the poor academic performance. Henry & Eng are not happy with each other’s disciplining methods. Henry has on many occasions ended up in physical fights with Ed while disciplining him. Eng is warned by Henry not to interfere and to leave the disciplining to him solely. Eng thinks that Henry’s methods will not work.

Prior to meeting Ed, I aimed at establishing a respectful relationship with the couple on separate sessions by finding out their individual expectations of Ed, and giving credence to their concerns and goals. At the same time, they were helped to view themselves as caring parents and as experts on their own children. I sensed that although Ed is better able to describe his problems at age 15, he also might be more defensive and reluctant to do so. He would probably be self-conscious and vulnerable when being asked to disclose things he felt confused and uncomfortable about. Therefore when Henry conceded that Ed was an unwilling client of mine, I did not take offense.

Constructing the genogram of Henry & Eng (Appendix 1) during the counselling process help they and I discover the unique pattern of interaction between individuals in the family. I would discuss next how I approached Ed’s case using Solution Focused Brief Therapy based on the 8 basic assumptions, solution-building stages & questioning techniques found therein. (DeJong & Berg, 1998) Lastly, I would state the strengths and limitations of this approach.

Approach based on Solution Focused Brief Therapy (SFBT)

SFBT is guided less from a theory & more from a curiosity to learn what works. (de Shazer, 1985)
My mission as a therapist is to empower Ed to live a more productive & satisfying life. If I focus on his obesity or addiction, he may become discouraged & feel that he is a victim of some disease or dysfunction. Saleebey (1997) “People are always working on their situation… As helpers, we must tap into that work, elucidate it, find & build on its promise.”

The SFBT approach has developed a useful set of assumptions about clients, therapists and the helping process. Its practice proceeds from the following assumptions (Simon and Berg, 1999). I would like to illustrate them by incorporating them into my conversation with Ed using relevant questioning techniques.

Upon meeting Ed, I reassured him that I understood how awkward he must feel being brought to the session. I informed him that I would at some point into the session take a short break to give some thought to the conversation (Campbell, Elder, Gallagher, and Simon, 1999).

Therapist: Ed, I was told you have been regularly going for your weight-control review. Can I say you do care about having a better future?
[SFBT therapists ask pre-session change questions to identify what useful actions clients take before they see a therapist. For many clients, the very act of thinking about how therapy will make a difference for them raises possibilities (Miller, Duncan and Hubble, 1997). In Ed’s case, I affirmed him of his positive behaviour despite noticing a certain degree of unwillingness.]

From onset, I took the posture of not knowing in exploring Ed’s concern by inviting him to describe himself from his own perspective.

T: Ed, in order to help me understand you a little, how about describing yourself in just 2 words.
Ed: Er… Moody, Peace-loving …
T: U huh, peace-loving. Now, could you recall the happiest day you have spent with your father?
Ed: Er….. I must say it was the one NAG-free day we spent together.
T: That does explain your peace-loving nature, huh? How would you like to make NAG-free day a permanent feature in your family life?
Ed: If only I can be left to do things all by myself, with no nagging from my parents or anybody.

T: You attended the medical review for your weight-control programme this morning and now you are here wishing for NAG-free day. These are positive changes that can make a difference in your life & such change is already happening by you doing the above.
[Assumption 1 – Change is constant and inevitable.]

Ed: I have no choice but to listen to my father & do what the doctor asked me to do. I will just finish the slimming pills and see what happen next.
T: You are sensible enough to set small goals.
[Assumption 2 - Small change leads to bigger changes.]

Ed: Actually I have lost some weight already.
T: Wow! What did you do apart from taking those pills?
Ed: Sometimes I forgot to take so I have to try to remember to take them regularly to help suppress my hunger pangs...
T: Great, what will you keep doing to lose more weight?
[Assumption 3 – The past cannot be changed. Steve de Shazer (1985), a co-developer of the solution-focused brief approach, quoted Erickson: Emphasis then should be placed more on what Ed does in the present and will do in the future. It will help for me to dwell on the details of Ed’s past successes.]

Ed: My father nags at me every day to get me to jog. He pays me $5 an hour if I do so.
[Assumption 4 - People have the resources necessary for change and they are the experts on themselves.]

T: Your father is applying positive reinforcement to keep you motivated in losing more weight. What will it be like for you to have your father jog with you?
Ed: He won’t jog with me, lah. I think he will be too embarrassed to be seen jogging with me…
But I think it will be nice if he jogs with me…
[Assumption 5 - What people do has an impact on other people. The meteorologist, Edward Lorenz, coined the term “The Butterfly Effect” (Butz, Chamberlain and McCown, 1997.]

T: Do you think your father is embarrassed to be seen with you at the Weight-control clinic too?
Ed: I don’t know. May be. May be not. I think he is worried about me too.
T: Do you also sense your father’s care in other areas of your life too?
[Assumption 6 - Every problem has at least one exception. At this point, the focus of the therapy shifted from the description of the problem to details of exceptions. It was this shift that moved the therapy from problem management to solution development.]

Ed: He nags at me when I don’t study. You can say he cares for me but I just can’t stand it.
T: How do you think your father will stop nagging at you?
Ed: He allows me to play on the computer for one and a half hour. But when I exceed it, he will get upset and start to nag.
T: And that upset you ….
Ed: He does not understand there are days I don’t play because no one invites me to play. I hate it when he hides the computer cable ..
T: I hear you say you stay away from the computer if no one invites you to play. It shows that you do have a good amount of self-control and will-power. What did you do instead?
[I asked Exception Questions to allow Ed to reflect on his positive behavior.]
Ed: I read a book.

T: Thank you for your input and feedback. What do you think you need to do to stop him from nagging again?
[I moved on to ask future oriented questions. These questions move the conversation from details of the problem to possibilities of how Ed’s life will be better in the near future.]
[Assumption 7 - Every human being, relationship and situation is unique. Erickson designed his therapy differently for each client (O’Hanlon, 1987). This process of fitting the therapy to the client requires client input and feedback.]

Ed: I guess I’ll have to stick to the one and half hour play time lor.
T: Does it make you feel in control of your life too?
Ed: I don’t like to be told to stop playing.
T: How do you keep yourself from exceeding the one hour and half?
Ed: It is very difficult but I have to try lah.
T: If you stick to the one hour and half, your dad will not say a word. How would this change in your dad make a difference in your life?
Ed: It would be like heaven on earth!
[I would at this juncture pose the Miracle Question to further encourage conversations about a better future.]
T: I’m going to ask a strange question. [pause]
Let’s suppose that after our conversation, you go home tonight and go to sleep. [pause]
While you’re sleeping, a miracle happens. The miracle is that the problems that we talked about are gone. [pause]
You can’t know about the miracle since you’re asleep.
When you wake up in the morning, what will tell you that the problem is gone?
Ed: I don’t know….perhaps I have lost all the excess weight when I look into the long mirror. And the dark ring around my neck disappears.
T: What else has changed?
Ed: I felt elated and eager to step out of the house.
T: Uh huh?
Ed: I was relieved the computer is still around…. [smile]
T: What else would you be eager to do?
Ed: Er…. I think I would do the things I have not done for years, like a visit to the national library or to catch a movie with my friends. Even to the gym to keep fit.
T: Wow, these are wonderful activities you can enjoy to make your life better!
[Assumption 8 - Changes come from many directions. Therapy is not the only way people change. According to Miller, Duncan and Hubble, (1997): “Research shows, in fact, that improvement between treatment sessions is the rule rather than the exception.” Ed is encouraged to take advantage of the many resources he can utilize by focusing on what makes his life better between sessions.]

Taking the Break
[As I did not work with an observing team behind a one-way mirror, I formulated the feedback on my own.]

After the break, I invited Ed & his father back into the room for feedback.
T: Ed, it is perfectly understandable that your parents reacted to the current situation you are in.
And they are not alone. I would like to reflect on your preference, dreams, interest, ability, resources… that we spoke about during the conversation… [The feedback is taken directly from what Ed has said. His key words are used as much as possible.]

At the end of the session I posed a Scaling question to expand on both exceptions and future visions.
T: I would like at this juncture for you to rate yourself on a scale from zero to ten where your determination level is to tackle the problems you are facing.
Ed: Err… It was at 2 before I came...
T: How did you stay above zero?
[I asked coping questions to elicit anything Ed has that implies that he has done something positive toward solving the problem. This reminds Ed that he has been successful in achieving small tasks.]
Ed: I think my father’s helping me a lot. May be without him, I could be at 1.
T: Uh huh. That still exceeds zero. How about now?
Ed: May be 2.5 ..
T: Great, that is a good 1.5 points increase. And you are already on the way toward a 10.
How did you know that you have moved to 2.5 and how that will make a difference in your live?
Ed: I think my dad needs help. He is tired of nagging … I will try my best … the difference is now I am no longer upset with my father for bringing me here…
T: [To Henry] What do you know about your son that tells you that he can learn to follow the rules?
Henry: I know he can. He had done so in the past.
T: Uh huh..

Strengths & Limitations of SFBT
Strengths

The focus is on the future instead of the past. It is a solution talk instead of dwelling on problems.

By allowing the Client to self-intervene, we can expect him to take ownership of solutions.

The approach is less prescriptive therefore good for mandated client as solutions are developed collaboratively.

The client is empowered to take charge of his own life. (De Jong & Berg, 2002)




Limitations

During the questioning phase, the challenge is for the therapist to avoid asking closed questions which can shutdown curiosity as such questions invite “yes” or “no” answers. (http://www.subud-britain.org/journal/article.html?article_id=79 retrieved on 23, August, 2006.) Some feel that the Brief model, with its emphasis on brevity and focus on finding solutions, do not take enough time to explore the causes, affective states, and experiences of the client. There is limited opportunity for catharsis. Emotions are respected but not fully addressed due to little insights into client’s struggles. The next question is therefore: can lasting change happen – briefly?

Another downside, poorly motivated & hostile clients will require therapist who have the skills of handling resistance and know something about “motivational interviewing” to get them going. In another instance, clients who have a history of poor relationships will need a helper who is able to establish a collaborative working alliance. The third group of clients who can pose as a challenge will be those who are passive, of low IQ as they may not be able to derive solution by themselves.
(Egan, 2002)

Summary
Research has shown that brief interventions can produce substantive & lasting changes. Brief therapy can be brief but comprehensive (Lazarus, 1997). The SFBT conversation helped me to focus on developing with Ed a well-formed goal & simultaneously, leading to solution-building. Such conversation can be described as individuals engaged in the process of meaning-making. (de Shazer, 1991) Recounting the past mistakes & poor performance would have turned Ed off. Educating or enlightening Ed would be redundant as his teachers & parents are already doing it. SFBT approach inherently fosters a respect for Ed while working on resources, success & solutions.

References

DeJong, P., Berg, I. (1998). Interviewing for solutions. California: Brooks/Cole Publishing.
De Shazer, Steve (1985). Keys to Solution in brief therapy. New York: W.W. Norton & Co.

Saleebey, D. (Ed.).(1997). The strengths & perspective in social work practice. (2nd ed.). New York: Longman

Simon, J. and Berg, I. (1999). Solution-focused brief therapy with long-term problems. Directions in Rehabilitation Counseling. Vol.10, Lesson 10, pp. 117-127

Campbell, J., Elder, J., Gallagher, D. and Simon, J (1999). Crafting the ‘tap on the shoulder.” A compliment template for solution-focused therapy. The American Journal of Family Therapy. 27;(1):pp.35-47

Miller, S., Duncan, B. and Hubble, M. (1997). Escape from babel: toward a unifying language for psychotherapy practice. New York: W.W. Norton & Company

Butz, M., Chamberlain, L and McCown, W. (1997). Strange attractors: chaos, complexity, and the art of family therapy. New York: John Wiley & Sons.

O’Hanlon, William (1987). Taproots: underlying principle of Milton Erickson’s therapy and hypnosis. New York: W.W. Norton & Company.

Egan, G. (2002). The skilled helper. California: Brooks/Cole Publishing

Lazarus, A.A. (1997). Brief but comprehensible psychotherapy: The multi-modal way (Springer series on behavior therapy and behavioral medicine). New York: Springer.

De Shazer, Steve (1991). Putting difference to work. New York : W.W. Norton & Company