Individual Clinical Supervision To my delight, A Tan agreed to my proposal to meet for 2 hours each time. That works out to 5 sessions over 5 months and hopefully all the sessions will end by Oct, 2006, as planned.
A Tan was at his office waiting for me when I arrived 5 minutes to 2 pm. I brought 3 cases with me but we had time only for one case. As this was our first meeting, we spent some time sharing about our background, current pre-occupation & future plan (in my case). I learnt that A Tan is a REBT practitioner. He was analytical and skilful as he helped me with my queries. I was impressed by his sincerity, warmth and humility.
The case we discussed during this session was on CL who is having problem coping with her husband’s drinking habit. Although this has been an issue for years, CL finds it increasingly difficult to accept it, especially after having gone through a rough patch recently when her husband had a mild heart attack. She is losing respect for her husband whom she looked up to in the past for moral support. Presently her husband has returned to his old drinking routine of 6 cans of beer nightly (Monday to Friday) and coming home near midnight, tipsy & talking incessantly.
CL has planned to draft a legal letter to demand her husband to quit drinking right away or she will leave him. She admitted that such thought arose as a result of frustration and anger. I acknowledged her emotion and led her to examine the underlying emotion, that of anxiety she is experiencing each time her husband returns home late.
I have learnt that CL’s dad was a heavy drinker. CL was devastated when her dad passed away suddenly as she was close to him. It is likely that she is afraid of losing her husband in the same manner. I have encouraged CL to articulate her anxiety to her husband rather than getting angry or having cold wars. I have also explained to her our functional ego states and how she could communicate to her spouse more effectively.
A Tan and I deliberated on CL’s value system and what she wanted to see change. At this point in time we are not certain if he has an addiction issue. To CL’s spouse, it is merely social drinking. I gave CL information on CAMP @ IMH. It is a programme to help rid addiction. CL will need to convince her spouse the need to seek help. A Tan has helped me expand the therapeutic horizon and I learnt new things each time I came away from the interactive supervision.
Cognitive Behavioral TherapySome basic CBT knowledge acquired while pursuing a Counselling Psychology Diploma previously prepared me to some extent what to expect from Dr Irit. I found the history & evolution part of CBT rather interesting. Surely the name Pavlov rang a bell because his Classical Conditioning kicked off my previous endeavour in Counselling Psychology studies.
Being a stay-at-home mother, I employed Operant Conditioning on my children all the time to elicit desired outcomes. Personally I believe that understanding my children’s individual functioning has helped me to approach them with the appropriate stimulus.
In the earlier years my approach was in the order of Positive punishment (Canning on the walls more than on their legs, tho’), Negative reinforcement (Nagging), Negative punishment (No ice-cream),) or Positive reinforcement (Praises). I believed this could be the pattern I was brought up with and came to accept it as the way to go.
However, as the children grew up, I perceived that a varied approach towards them have to be adopted to sustain positive and effective outcomes. It was a complete reshuffling to Positive reinforcement (monetary incentives), Negative punishment (No computer), Negative reinforcement (Nagging), or Positive punishment (reserved for capital offences).
I find the Cognitive Model helpful in helping me understand why my child behaves the way he does. The main issues we grappled with centered around their academic performance and at one point, computer game addiction of my younger son. He turned moody, teary & upset when the computer was disabled. He chose to just idle or sleep instead of studying when he had no access to computer. Physiologically he seemed lethargic & listless.
On probing further, his Negative Automatic Thoughts consisted of `I have lost my only recreational activity’, `My gaming friends may not play with me in the future’, `my parents fail to recognize my prowess in computer gaming’ etc etc.
To be able to access his `internal dialogue’ and to sort out the series of unproductive thoughts that flowed through his mind requires timely intervention in a gentle and loving manner.
Solution-Focused Brief TherapyMr Edwin attributed his successful approach in SFBT to 15% in the model, 15% on hope in Client, 30% on rapport with Client & 40% on the extra-therapeutic factors the Client brings into the session.
The focal point I observed from Mr Edwin’s sharing is that resilience in Client makes SFBT work. The therapist serves as the therapeutic tool - the resourceful person. In order to shrink the problems in Client’s life, the strategy is to acknowledge the problems but talk about the strengths, qualities & possibilities – essentially a therapeutic dance in communication. The process is akin to bringing him/her with what he/she has to where he/she wants to go.
As a counselor, the `play with language’ will certainly determine the level of rapport I can established with Client. Even in my dialogues with my significant others, I believe by re-framing & re-phrasing my words, I can help reinforce certain qualities in them.
For e.g., instead of using the descriptive word `stubborn’ which is negative, I can choose to use `persistent’ or `determined’.
I had the opportunity to apply what I learnt from Mr Edwin the therapist on a teenaged boy by the name of Ed recently. Although the latter’s prominent problems were obesity & online game addiction, I did not focus on his problems. (Incidentally, his obesity is being monitored by a medical doctor.) Due to a low level of confidence, he was unable to accept how his problems could be resolved in a miraculous manner. So I devoted more time looking for exceptions by asking about times when he chose not to play games.
In an attempt to elicit more positive behavior, I emphasized on what Ed is already doing to solve the problem, e.g., his ability to stay away from online gaming if his friends do not call.
I encouraged Ed to take charge of his life by keeping time when playing. For this will also stop his parents from nagging at him.
These days I find myself adopting Exception Finding Questions, Scaling Questions & Coping Questions in my mediation/counselling sessions at the court too. And when clients are made to reflect, they are more likely to continue what has worked for them in the past and to try new strategies as well.
Mental DisordersI always count it a joy to be under the pupilage of Dr C T Tan, irrespective of how brief the session may be. He exudes a fatherly figure and is blessed with intelligence, wisdom, grace & lots of warmth. With years of experience as a psychiatrist, he has much to offer. And I was glad he did it simply and in good digestible portion, & nearly always illustrated with relevant cases.
Once again, I learnt to distinguish the differences between Neurosis (SAD), Psychosis (MAD) & Personality Disorder (BAD). The neurotic exhibits symptoms such as Anxiety, Depression, Phobias, OCD & PTSD. On the other hand, a psychotic may be deluding, hallucinating or loss of touch with reality (DHL).
I was surprised to learn that Qi-Gong practitioner who becomes overly involved may experience psychotic symptoms. Although I have never attempted such sport, I was rather regular in my yoga pursuit some years back. I decided to come out of it when I experienced much unease during meditation and disturbed by the unpleasant sound of chants.
DSM IV was heard of for the first time & I was glad Dr Tan gave the wise & timely admonition that I should refrain from being an idolater of it. Also for the first time I met a Schizophrenia sufferer who looks as normal as anyone of us in the class. He is the good-looking Harris Ng. Dr Tan demonstrated how to communicate with a mental patient such as Harris. There was a lot of gentleness & affirmation.
Harris’ books entitled `Recovered Grace: Schizophrenia’ were autographed by the writer most willingly. I found the time to read the book days later and was enlightened by his frank sharing and tickled by his sense of humor. After reading the book, I felt a burden being lifted off my chest. More aptly the fear of being in the presence of schizophrenia is now a thing of the past. Through Harris, I have learnt to recognize the human-ness in schizophrenia & have willed to stop 'dehumanizing' them in future.
AnxietyOne in every 10 Singaporeans is ANXIOUS! Wow! The pleasant news is ANXIETY is non-existent in Dr Ang’s class. Under the spell of his wit & humour, we learnt about ANXIETY with much ease.
When Dr Ang was describing about Social Phobia, I felt to some extent the relevancy of it in my life at some point. Although my parents are friendly & warm, they are not vocal but reserved by nature. Their children have, by and large, inherited their nature. We are a brood of shy and quiet people who avoid at all costs the limelight & of being the centre of attention.
I recall being informed by the court last June to anticipate an interview by the press for having won the Individual Award in The Subordinate Courts Benchmark Awards for Volunteerism 2005. My heart missed many beats as anxiety welled up within me. The thought of opening up my inner self to the public was a discomfort, to say the least. The ‘saving grace’ came when our family trip to Perth was confirmed by the airline. So relieved I was to avoid successfully the situation that would have generated some panic attacks. Being the center of attention can be very unpleasant for me, indeed.
What I encountered at court yesterday was memorable for me. For the first time I had an OCD sufferer for a client. I recalled what I learnt in class and looked out for her tell-tale signs. She was stunned and extremely anxious when I picked up a document from the floor. I offered her some money for lunch as she claimed she had spent her last dollar. But she had to turn me down because my money was full of germs and she could not bear the thought of handling it. She even refused to accept a new bottle of mineral water from me when she said she would just drink some water instead.
I felt really sorry for her homeless state. Her family admitted her to the IMF due to her medical condition. She was subsequently discharged due to default in payment. She has been sleeping on the bench at Changi Airport in the past one week, happy with the clean & air-conditioned environment, away from the mosquitoes, flies & insects.
Her husband explained that the maintenance money given to his wife was spent on soaps, detergents, etc. He & family members could not take her washing ritual anymore. He could be in a denial state when he commented that she was merely putting up an act. I was glad when he indicated the need for further counseling support.
Attachment to Mt E-Charter Behavioural Health Services There were 60 of us showed up at the Mt E-Charter on the 10th level of Mt E hospital. After signing the Patient Rights & Confidentiality Agreement, we were divided into 2 groups led by 2 young professional staff on a ward tour. I was expecting to witness an ECT procedure. Even the patients were no where in sight.
We were briefed on the Treatment Team Core members & approaches of Mt E-Charter. The professional conduct of the Counsellors were being stressed – boundaries, confidentiality,….
I find the assessment of client @ Mt E-Charter rather comprehensive and thorough – leaving no stone un-turned:
- Observation of behaviour & presentation
- Background behaviour
- Current functioning (work, social, family)
- Self-report of problems (verbal or checklist)
- Caregiver perspective of problems
- Formal assessments (eg IQ, suicidal..)
- Evaluating whether referral to another is appropriate or indicated
The counselor is expected to acquire the knowledge of the symptoms, the natural history of a disorder and the effective treatments. The client has to be educated to help them adhere to the treatment plans. The acquisition process of such knowledge will serve as ongoing learning and skill development.
I enjoyed the art therapy session thoroughly. It was a journey-in and self-discovery adventure. I discovered the artistic side of me.
First Intake Interview The new Training Centre was not difficult to locate as we had 77 year old Vincent with us. He is very familiar with the Katong area. The steps leading up to the classroom were many and quite a challenging climb for some of us. To my surprise, Vincent took it in good strides. He has the `material’ to take on the Masters Program, indeed! I am about 80% keen on furthering to the next level.
Jessica shared with us gems related to first intake interview. One of the goals of a counseling assessment is to give hope. I will have to be mindful that I don’t make promises that the distressful circumstances will definitely improve, although that may be what the clients want to hear. Rather, I am there as a counselor to offer support and encouragement that change is possible if the client tries.
The 6 Cs of counseling are Contact, Connect, Contract, Content, Change & Closure.
Contact & Connect form the therapeutic alliance. Client then Contracts with self to renew self, behaviorally &/or emotionally. I am reminded that Content of contract has to be clear & achievable to promote Change. And the treatment plan is fluid, constantly being reviewed. Finally a Closure – an understanding insight, an `aha’, some `hope’ of sort.
Richard Nelson-Jones (1993)’s Helping Model:
D eveloping relationship
A ssessing problem
S tate goals
I ntervene
E nd
Suicide Prevention Crisis ManagementWe spent two interesting Sundays with Mr Soh who is a seasoned life-saver.
It was indeed a privileged learning experience to be coached by him on this `life & death’ subject.
I have not been exposed to crisis of a massive nature therefore am not able to imagine how I can handle one. One course mate had gone on medical mission trip to treat survivors of natural disaster and returned to share about her experience. It was enriching to listen to how she was enabled to cope with the devastation and sorry sights by the resilience of the victims!
The class was asked to do a survey on suicide ideation/thoughts by Mr Soh. The Score for ‘No such thought’ was rather high. I put down ‘Sometimes’ because I do think of it whenever I miss my father too much. Ironically, when I was growing up and unable to cope with father’s constant shelling, I too had attempted suicide.
Most of the time I agree that suicide is irrational and cannot be justified. For when I commit suicide, I am telling my Creator God He has created me in vain. And that His Son Jesus has died on the cross in vain too. This belief has kept me from taking the pre-matured exit.
I learnt that suicide is a coping mechanism; one cannot take it away without replacing it with something else.
I learnt also that the 3 most important factors to look into when assessing suicide risk are:
1. Current suicide plan
2. Prior suicidal behavior
3. Resources.
It can be really dramatic & draining to try to dissuade someone from taking his own life. I salute Mr Soh for his untiring effort and great passion in the work he has been doing for many years. I am impressed by his devotion and zeal.
Ventilation & New DevelopmentI have been thinking about my mediation & intake interview involvement at court. Undeniably, it has been enhanced by new knowledge & skills acquired at ECTA.
I have even begun to view my technique at FC as mediative-counselling. If I can resolve a financial issue at an one-off mediative-counselling session, that's to me a success. And when the need arises, the clients are offered the choice to have other issues in their lives addressed outside the court premise.
I was cautioned as I might appear to be soliciting for clients at FC. I was somewhat baffled. I am not paid by ECTA nor FC nor the clients who are mainly from low income group. (Even the $20 per hour at free clinic @ ECTA is a burden to them.) So if client is not made to pay for counseling, how can it be deemed unethical?
As a volunteer, I am not in a capacity to dictate a change in the way clients are being handled at the court, in terms of time & manner. Very often I come across clients who struggle with their daily functioning. I wish I could do more, at the very least, offer more time for them to ventilate and reflect, & hopefully derive at some positive outcomes based on the limited resources they have.
Since early August, I have been helping out at the FTPU of Family Justice Court to interview/counsel victims of family violence. I have to
a) assess the history of the case and the risk of family abuse to the Complainant and/or the children;
b) inform the Complainant of the court procedures and processes involved in the application for a protection order;
c) educate on safety measures and the effects of family violence on the Complainant and the children;
d) assess the case for suitability for counselling; and
e) refer the Complaint to other relevant services such as crisis shelters and welfare organisations.
(The above interview is supposed to take 20 minutes per case. I feel strongly the victims in crisis should be given at least 30 to 45 minutes during their first visit to court as the trauma is most intense at this point for some.)
Counselling Research Project (CRP) 1st round Meet Our group met to discuss on the project which is due end of Sept. At the end of the first session, and having made sense of the requirements, we were a picture of relief.
We started off trying to define Culture. I liked this one:
It is said that culture is a human necessity and a way of life. It is the core of internal ways in which human beings develop their sense of self, including values, beliefs, thought patterns, perceptions, and worldview. All these qualities help determine and shape one’s external culture; in other words, the way(s) in which one establishes and maintains a relationship with the environment and others through implicit norms, language, traditions, rituals, and loyalties that influence attitudes, behaviours, and customs (Gushue, 1993).
Effectively, I am a culture on my own which makes up the sum total of a culture of a group. I am unique to the core as my worldview is shaped by my upbringing, environment, significant others..... so much so when I interact with another human being, we will need to `enter' the other person's `world' to fully understand each other. This is certainly challenging - until and unless I am `invited', I can only know a person to the level of his/her comfort. Some men may avoid revealing the vulnerable side of them, as a Counsellor, my focus will have to shift from targeting their emotions to `what can be done' to improve the bleak situation.
'Family culture' refers to rules that we abide by in our own little family unit, for e.g. mummy will be the first to discipline the child, when it doesn't work, the dad will step in... etc. I recalled the case of the Chinese couple from China seeking PPO at court. The husband was viewed as `inferior' by his wife from a different province in China. His wife was `chastised' (beaten up) for behaving uncouthly, typical of the province where she came from. As a Counsellor, I was at a lost as to know what's deemed acceptable by both. Taking on the case will mean learning from them as the session goes.
Culture in CounsellingTo me, culture takes centre-stage in counselling. What both counsellor & counsellee bring into the counselling session are two sets of unique cultures. The quality outcome of the counselling session depends much on the interaction and inter-connectedness of the therapist & client. As the helping profession requires that the counsellor establishes a therapeutic alliance with the client so as to empower him to make positive changes to his life situation, the onus is on the counsellor to align himself culturally with the client. It is therefore of paramount importance & a primary task for the therapist to be able to embrace the client coming from a diverse culture unconditionally in order to win the latter’s trust & acceptance.
I am familiar with the Chinese culture but having exposed to the clients at the court, I realised that Chinese in Spore, Msia, HK, Taiwan…. even China itself are culturally diversed. During counselling, from time to time, I find myself `stepping back’ and learning about Chinese culture unique to e.g. Taiwan or a certain province in China.
I am propelled as a Christian to imitate Christ – to regard others positively & unconditionally. I believe that all men are basically good. We do falter from time to time but if God the Creator has provided the redemption for the fallen nature of men, who am I to judge and condemn? Also, I believe in the embodiment of Christ as detailed in Matt 25: 34 - 40
34 Then the King will say to those on His right hand, ‘Come, you blessed of My Father, inherit the kingdom prepared for you from the foundation of the world: 35 for I was hungry and you gave Me food; I was thirsty and you gave Me drink; I was a stranger and you took Me in; 36 I was naked and you clothed Me; I was sick and you visited Me; I was in prison and you came to Me.’
37 “Then the righteous will answer Him, saying, ‘Lord, when did we see You hungry and feed You, or thirsty and give You drink? 38 When did we see You a stranger and take You in, or naked and clothe You? 39 Or when did we see You sick, or in prison, and come to You?’ 40 And the King will answer and say to them, ‘Assuredly, I say to you, inasmuch as you did it to one of the least of these My brethren, you did it to Me.’
I `see’ Christ embodied in my client & Christ that’s embodied in me gives rise to the compassion I have for him. Helping is therefore motivated by a personal spiritual conviction.
I grew up in a small town sharing compound with Malay (the ethnic majority in Malaysia) & Indian neighbors. My experience living side by side with them was pleasant. There was racial harmony, neighbourliness, & strong bonding. My parents’ whole-hearted acceptance of them resulted in me having an Indian christian bro-in-law & a Malay muslim bro-in-law. As an ethnic majority in Spore, my worldviews towards the other ethnic groups remain unchanged. My view of them is again spiritually inclined. We are but sojourners travelling through this world together.
