Nothing Stands in Son's Way

The Combat Diver Course is a 31-week course specifically designed to train military divers of the Navy. The course is divided into four phases as follows: Phase 1 is the Physical Phase, where trainees go through strenuous training to train up their physical and mental strength. This phase ends with the Team-Building Week, more famously known as "Hell Week". Phase 2 is the Diving Phase, where trainees are taught techniques in basic diving, as well as land and underwater demolition. Phase 3 is the Land Combat Training Phase, where trainees go through land-based training. Phase 4 trains shipboard competency. (http://www.mindef.gov.sg/imindef/mindef_websites/atozlistings/navy/microsites/ndu/index.html)

It was with great jubilance as the family witnessed the Passing Out Parade of Clem from the Diving Phase of Combat Diver Course on 10 Nov 07. He is now in Phase 3 which is the Land Combat Training Phase.

NDU is the only unit in the SAF that specialises in diving. The bulk of NDU’s responsibilities lie in search and rescue (SAR), explosives ordnance disposal (EOD) and general salvage work. Readily responsive to calls for assistance, our naval divers are also involved in less critical situations, such as “evidence recovery.” MSG Norris Charles, a veteran instructor, said: “There was once in 1994 when we spent five hours below Anderson Bridge recovering a gun which was accidentally dropped by a robber!”

One of the most challenging tasks for the EOD divers took place in 1990 when a team of 60 divers worked around the clock for three days to clear 21 World War Two bombs in the waters off Pulau Brani. MSG Charles who specialises in EOD said, “Mine clearance is a very long process, as it can take days, weeks or months. All EOD divers have to attend a specialised course before they qualify as mine clearance divers.”

He emphasised: “Of course, safety is top priority. We inspect every single diver before diving to ensure that his equipment is fully demagnetised to prevent any explosions when approaching underwater mines.

“On top of that, every mine clearance diver goes through currency drills under close supervision every quarter so that he is thoroughly familiar with all the standard operating procedures.”

Although naval divers operate primarily underwater, they are certainly not “fishes out of water” and will surface in times of need. NDU’s combat capabilities include shipboarding, force swimming (groups of divers swimming in formation) and close quarter combat. Such capabilities are necessary when hostages have to be rescued from hijacked ships or when ships suspected of carrying contraband cargo have to be boarded and searched. SSG Eric Tay, a combat-trained NDU diver said, “Compared to normal salvage jobs, combat diving is a different ball game altogether. There are special tactics that you need to learn. In order to be a good combat diver, you must also possess situational awareness and survival instincts.”
He added: “Fitness also plays a part, because you are not just diving. You also have equipment and weapons, and you will have to swim fast. The diver’s mental state is also very important, as in how much you can motivate yourself to achieve your objectives.”

PUSHING TO THE LIMITS

A firm grounding in physical fitness and mental agility is provided to all trainee divers during the training process at NDU. As in all cases, training builds the competence required to perform the job. However, it is a little different in the NDU, where every trainee diver knows that the training will either “make or break” him, depending on his determination to persevere through the rigorous training.

It takes about six months for a trainee diver coming straight from Basic Military Training to complete his Class 2 Diving Course, where theoretical and practical knowledge on diving is imparted. To build up the trainees’ water confidence level and their knowledge of how their equipment would perform underwater, a pool competency course is conducted in the first half of the course. Under the watchful eyes of the safety officer, trainee divers are subjected to simulated stress akin to actual underwater conditions.

Each diver’s performance is closely monitored to ensure that he is competent in managing potential underwater problems. During these drills, all trainees must maintain a cool composure and alert mind to be able to extricate themselves from the problems that they face underwater.

After he clears this stage, a week of sweat and toil awaits him. Popularly known as ‘hell week’, the old adage - the survival of the fittest - certainly applies here. Hell week means a gruelling 120 hours of non-stop physical exertion both on land and in water, with trainees allowed three hours of sleep only on the third day. Only the best will make it.

SSG Tay said: “The aim of hell week is to let each individual know that he can be pushed beyond his limits. There is a saying that the human brain is about 10 times stronger than the body. There’s no way you can test a person’s psychological strength until you break his physical strength first.

“So the first three days of hell week are very physical. However, you must keep on going if you want to succeed. Those who quit will be deemed unsuitable to be naval divers. You have to be a team player to survive. There’s no ‘Rambo’ in the Navy.” If you thought that hell week would be the culmination of training, guess again. Naval divers have to brace themselves for another three months of basic combat training before they can graduate from the course. In this last phase, trainees are taught the rudiments of combat tactics. In an exercise called drown-proofing, trainee divers are dumped unceremoniously into the pool with their hands and legs tied. They are then required to bob up and down in the pool, swim for about 100 metres and perform manoeuvres like somersaults underwater.



Without a doubt, our naval divers are all set to create a deep impact in the new millennium. “Nothing stands in our way” was the motto adopted by NDU in 1995 to reflect the daring and “can-do” attitude of the divers. You can be sure that with the tenacity, grit and determination of our naval divers, nothing will stand in their way.

(http://www.specialoperations.com/Foreign/Singapore/NDU/Default.htm)

Snapshots

Snapshots of Thoughts;

Canvas of Soul....

Advanced Counseling Issues & Advanced Counseling Intervention II

Mr Tan’s idea of counseling as a good piece of conversation goes hand in hand with the art of integrative therapy. The goal of the therapist is to have a purposeful relationship with the client. The BIG event is to ‘socialize the client into and through the counseling process’. More often than not, the client has no love for self, live for others and often desiring to change according to the therapist’s suggestions.

The therapist then has to exercise ‘control’ (how much and how fast) of therapeutic intervention. The key is ‘do as client’s able to.’

I learnt that anger is not a primary emotion. It masks fear, anxiety and hurt. In fact it is a defense mechanism. As a symptom, it therefore connects with other feelings. Normalizing the anger may slowly allow the other feelings to surface. The client must trust me enough to want to reveal the more vulnerable side of him. My existential approach will require me to stay in constant touch with his emotions:

What are you experiencing?
What were you feeling?
What are you feeling now?

I would help client to gain greater awareness by contacting his raw nerves:

‘If I were her, how would you talk to me?’ (I would emphasize on the psycho-presence of her in the session.)

I would point out his non-verbal behaviour and talk about it. Ultimately client must know he cannot Control, Change and Cure his significant others.

When dealing with resistance of client at some point during therapy, I will need to re-assess client’s problems and revisit goals set at start of therapy. Resistance is part of therapy and therefore client’s readiness is crucial. On the other hand, role-play can be used to identify negative feelings, to explore and challenge them if necessary.

The grounds for termination include: Goals achieved, goals not achieved (poor fit), client refused to engage, and client refused to pay fees (I would consider a reduced rate or pro-bono if client goes into financial difficulty) or client decides to stop.

Advanced Counseling Issues & Advanced Counseling Intervention I

It was touching base with self and one another when Mr Tan seated us in a circle and requested each one of us to share about the following:

1. Where am I as a counselor?
2. How did I come into this field?
3. How did I see counseling as I started out?
4. How have my views about counseling changed?
5. How do I presently work as a counselor?

My counseling journey started out with me embarking on the Counseling Psychology diploma at the LEE College. I wanted to understand why people behave the way they do and how I can impact a positive change in people’s behaviour. Over the years at LEE College and ECTA, I have come to grasp the intricacies and dynamics of interventive counseling. This is far from the view I once held of counseling. Interventive counseling requires me to be actively listening, being both humanly and professionally present, tarrying with the client when she enters the seemingly bottomless pit and waits while she bottoms out of it.

The counseling equipping has made me more psychological-minded. It increases my capacity to empathize more, especially towards my significant others. My theoretical orientation is geared towards a CP framework. When the need calls for a walk back to the family of origin, I will employ Redecision Therapy. I have also started using CBT to address distortions in thought pattern. I believe these will be the 3 primary approaches I will introduce in my counseling work.

I am happy where I am today. I think I am a good enough parent, a good enough mediator and a good enough counselor. With God’s help, I expect myself to grow, develop and mutate in terms of effectiveness and potency.

The purpose of the above exercise is to slow us down to be introspective, to reflect and to take stock. Mr Tan reminds us that ‘to advance we need to retreat’ for our souls to catch up. There is a need to look ‘at’ self and ‘within’ self in order to grow deeper.

It also makes comical and psychological sense when he shared that ‘it takes 1 counselor to change a bulb, but the bulb must want to change.’ When I look with client in empathy and look at client professionally, I need to find something lovable and good about him.

QBC's 45th Anniversary

Timo and i are in a 60-strong choir to sing a modern contemporary song, a Negro Spiritual song and 'Halleluiah from Handel's Messiah'. I am singing soprano while Timo tenor (He has been shortlisted to sing tenor in the coming Christmas acappella). It's a wonderful experience to return to a choir after more than 10 years and able to hit the high C note at this 'fragile' age. The weekly rehearsal have helped to strengthen the vocal chord and tummy muscles. :)

Hallelujah’ Chorus from Messiah


Messiah is an oratorio by George Frideric Handel based on a libretto by Charles Jennens. Composed in the summer of 1741 and premiered in Dublin on the 13 April 1742, Messiah is Handel's most famous creation and is among the most popular works in Western choral literature. The very well known chorus, Hallelujah, is part of Handel's Messiah. It concludes the second of the three parts. The text is drawn from three passages in the New Testament book of Revelation:

And I heard as it were the voice of a great multitude, and as the voice of many waters, and as the voice of mighty thunderings, saying, Alleluia: for the Lord God omnipotent reigneth. (Revelation 19:6)

And the seventh angel sounded; and there were great voices in heaven, saying, The kingdoms of this world are become the kingdoms of our Lord, and of his Christ; and he shall reign for ever and ever. (Revelation 11:15)

And he hath on his vesture and on his thigh a name written, KING OF KINGS, AND LORD OF LORDS. (Revelation 19:16)

In many parts of the world, it is the accepted practice for the audience to stand for this section of the performance. Tradition has it that King George II rose to his feet at this point. As is true today, when the King stands, so do all subjects also rise; thus engendering the tradition. It is lost to history the exact reason why the King stood at that point, but the most popular explanations include:
• He was so moved by the performance that he rose to his feet.
• He arrived late to the performance, and the crowd rose when he finally made an appearance.
• His gout acted up at that precise moment and he rose to relieve himself.
• After an hour of musical performance, he needed to stretch his legs.
Because this piece is so often heard separate from the rest of Messiah, it has become popularly known as "The Hallelujah Chorus", which, like "The Messiah", is technically incorrect usage. "(the) Hallelujah chorus" or "'Hallelujah' chorus from Messiah" is more proper usage.

Counseling the Disabled

Mr Dudley though blind did not show awkwardness common to the blind. That I mean though he walked hesitantly due to unfamiliarity of the environment, his demeanor, mannerism, composure and persona was as natural as a normal person. Hiding behind a pair of matching sun-glasses, he even looked rather charming with his smile which he generously gave from time to time. He was very involved and engaged with the class, no trace of loss-ness. The tone of his voice was calming, reassuring and inviting… It made me feel like he was giving me 100% attention when he addressed me.

Mr Dudley presented himself THE counselor one needs to be when counseling anyone, the disabled included.

‘It is the negative attitude that makes a disabled person handicapped.’ - there is just so much truth in this statement of Mr Dudley. I counseled a new client yesterday. Only 50% of her physical body is functioning due to a brain surgery that had damaged some nerves. Through out the session, she portrayed herself as one who is capable of overcoming setback and wants to move on in life. However, the negative attitude of her significant others (her beloved mother included) has made her feel truly handicapped.

According to Mr Dudley, counseling is a FEELING discipline. It calls for the counselor to be sensory aware, to remain positive and provide non-possessive warmth.

On the practical front, when counseling a disabled, we are not to touch a walking stick or wheelchair belonging to the latter. These things have become an extension of the patient. Touching their aids amounts to touching them.

Our posture when talking to the client is important too. It is ideal to sit at eye-to-eye level. Standing up and talk to the patient makes one looks imposing or intimidating.

Mr Dudley ended the session with a skit written by him and read out by some of us in class. It was about a blind man’s struggle to come to term with his sudden blindness. We understood better as we analyzed how the social worker in the story could have improved on her therapeutic approach towards the blind man. I realized too the significant roles played by the significant others in the life of a blind person. I think Mr Dudley had used a powerful tool in sharing valid and essential points in counseling the disabled.

Group Supervision/Dynamics

Dr Ng focused on Group Therapy and quoted I Yalom, the psychiatrist-turned-group-therapist. How interesting!

The main function of a group therapy is to provide support, psycho-education and intervention to about 8 to 12 members. Confidentiality is observed by the members in the group. Dr Ng expressed his own surprise that there is no existing Depression Support Group in Singapore. The group therapy process starts with a beginning (bonding/boundary setting), middle (working stage) and end (termination) stage.

The process may be short term which is energy-driven or long term for support and maintenance.

Before the group is formed, screening/selection will be conducted to determine the appropriateness of the group, the level of commitment. About 8 persons will meet privately for 1 ½ hrs per session. Rules will be laid down, such as ‘no drug/alcohol’, have to be present in all meetings, avoid sexual involvement/biases and ‘no physical violence.’ A list of rights, responsibility and expectation will be drawn up before the contract is developed.

The characteristics of a Group Therapy include an initial stage which looks into the likes and dislikes of the members, the worry about risk level and anxiety. The group dynamics allow modeling of leader, attending to fear/anxiety, creating trust, addressing issues outside of group. The group is seated in a round circle.

During the transition stage, the resistance, conflict, difficult behaviour as well as defensive behaviour will be examined.

The working stage provides members to work on the themes. There is self-awareness and intense emotions present at this stage and the focus is on issues. It is also here the progress is being traced.

The ending stage sees the therapist preparing the group for termination about 3 sessions before last session. The rituals include ‘good-bye note’. The future plan and new roles of each member will be addressed.

Advanced Counseling Issues & Advanced Counseling Intervention II

Therapy is made up of 20% content and 80% the process. The 1st two sessions are spent listening to the client’s stories which form the content of the therapy. Effectiveness in therapy comes with true understanding of the context – how client interpret key developmental events in fixed patterns & precipitating factors at the onset of maladaptive behaviors, etc.

For Adjustment Disorder, 12 to 15 sessions will be deemed sufficient. Intensive and frequent sessions will be structured in the early days of therapy, perhaps twice weekly and subsequently to reduce to monthly session for maintenance.

At some point, the therapist is to lead and control the session. If client is unstructured, such as becoming tardy in his attendance, such behavior will be viewed as treatment issue if it happens regularly. There is a place for therapist to define and control (stay on top) of how the therapy is to take shape. If the client fails to show up, it is ok to call him/her but not to pursue.

Homework is a necessary part of treatment and following-up with it is mandatory unless the client has more urgent issue to attend to.

Case Management –

Dr Ng recommended note-taking in the following manner:

Subjective (Client’s expression of himself or herself)

1. Client’s anxious.
2.
3.
4.

Objective (Therapist’s assessement)

1. C’s stuck in his/her …
2.
3.
4.

Action (Therapist’s intervention)

1. Referred client to IMH
2.
3.
4.

Plan (Homework for next session)

1.
2.
3.
4.

The therapy should provide a structure that is stable yet flexible. The 1st thing to find out will be how, why, how frequent the problem occurs. The CBT (12-step and solution-focused) comes into play after that. Therapist must seek to know the larger system (the support group).

Dr Ng touched on 6 constructive innovations in counseling:

1. Negotiating meanings – redefining and redirecting – the client’s unique view of meaning
2. Inquiring to conceptualize from a ‘not knowing’ stance by questioning.
3. Focusing on competence and resourcefulness of client. What works?
4. Eliciting & inviting – ‘How can I help in this regard?’
5. Client’s preference – Client’s theory of change. Unwavering focus.
6. Co-signifying audience – ‘intended audience’

The class watched 2 video clips on addiction and eating disorder. We were divided into 4 groups to approach the cases using our preferred modality. I joined the Redecision group and had a good time conceptualizing the case and detailing treatment plan.

The representatives shared the work of groups and I revisited the concepts and techniques of CP & PP. 

Dr Ng was impressed by the depth and breath we have on our preferred modality.

Advanced Counseling Issues & Advanced Counseling Intervention I

Dr Ng kicked off the session emphasizing the contextual reasons for clients to seek help. They range from conflicting values, poor financial management, seemingly irreconcilable relationships, etc. The first session with client calls for increased energy on the part of the counselor to engage and connect with the client. There is even a necessity at some point to take a 1-down position when addressing the client.

With all the information provided by the client, it is advisable to deal with them in segments or progressively. Therapist and client collaboratively find meaning and operationally defined relationships. Dr Ng’s dealings with alcoholics are progressive abstinence on the part of client and he ‘prescribes’ sex addicts with down-graded control for sex, e.g. instead of going to the brothel to stay home and watch a pornography on the puter. Patrick Cairns’s ‘Out of the Shadow’ will provide an understanding of what sex addiction is about and ‘Did you call it Love?’ details the treatment for such addiction.

The verbal and non-verbal behaviours of the clients will be observed reflectively (from therapist’s own experiential perspective). Open-ended questions are posed and summarization of content shared is given from time to time. Feelings expressed by client during the process is supported by statement, such as, ‘Certainly you are going through a difficult period.’

The emotional intercourse, or sharing, commonly referred to by therapist as intimacy between the client and therapist reveals the inner processes of the former. It is the job of the therapist to develop an interventive mindset.

Instead of advising, the therapist redirects. The focus is on the client’s context and using client’s language to fix the problem. In Solution-focused there is a huge distancing between therapist and client. The other extreme is observed in psychodynamic psychotherapy where therapist and client can be affected by transference. The trick is to compartmentalize the professional and personal life.

Psychodynamics of Romance

Romance is a partnership of love-story. It is how love is maintained. It is the exchange or language of love. Romantic love is the falling in love. It is ‘I love you because…’ It is vital to keeping the relationship alive. But real love is rising to love. It is saying ‘I love you despite ….’ When we get to know each other better, our brains start to settle down and romantic love transits to real love.

Mr Lim posed the question, ‘Why romance fades?’

Some answers captured: Familiarity breeds contempt – couples stop thinking about romance or work at it. Inherent need in people for colors in life therefore results in pursuit of different partners. Mutual needs not met. Specific needs not met. Some couple’s threshold for conflicts are low. No time for each other – couple connect only to complain.

A heterosexual couple are made up of two different personalities observing own specific boundaries but crave for each other’s attention, validation and to be doted on. There lies within each of us the need for security/stability on one hand and adventure/mystery on the other. This relationship is supposed to be sustained by affectionate love and fueled by passionate desire but the ‘ship’ sometimes is smooth-sailing, other times sink.

We discussed on why affectionate love is such a chore for the men. It is, as it means staying in touch with each other, expressing love in words and actions. And this takes time. The men are more attentive to their career once they have settled into the marriage. Ideally, the couple should attend to each other in love, shows their appreciation in love languages, acknowledge gratefulness by feeling it, showing it & saying it..

It is mandatory to maintain intimate contact with spouse. People thrive well when given praises. ‘I can live for 2 months on a good compliment.’ – Mark Twain

The most common obstacle that keeps couples from being intimate is the fear of being upset. And fear is the opposite of love.

Passion and intimacy needs to be injected into the conventional family for the couple to meet each other needs fully.

Visit to IMH

I was a little apprehensive at the thought of visiting IMH. I didn’t have the time to visit its website prior to the visit and was pleasantly surprised by what unfolded before my eyes upon arrival. It was nothing near what I imagined it to be. In fact the place has a resort feel to it after a recent revamp. 


We were given an introduction of IMH as a group at the auditorium by a young gentleman who is a medical social worker. Many things were shared but what I found to be noteworthy is IMH’s vision is to be the leading mental health centre in ASIA by 2012! The challenge to eradicate the stigma associated with mental illness is daunting. The strife to put the patients on equal stand with the people in the community is a commendable one, though. Public awareness and education will go a long way to reduce unemployment and discrimination at work place. The outcome is not a favorable one yet.


Barista Express is a social enterprise set up by IMH and run by recovered patients. IMH has also funded 50% of patient’s 1st two months salary as incentive for employers to recruit their patients. Patients go through vocational rehabilitation (e.g. FSRP – Food Service Skills Rehabilitation Programme) to equip themselves for employment. The snack bar, Juiceworks, in IMH is run by recovered patients.


Personally I was impressed by the Voluntary Rehabilitation Programme at the Stepping Stones. In-patients may be referred there before discharge. It is a 8-week programme designed to educate and train the patients. Making them understand why they need to learn is more challenging than teaching them how to do it. The patients are tracked on their social adjustment as well as adjustment to medication. The attrition rate is very low as majority of the patients benefited from the programme.


I left IMH feeling unfulfilled. I wished I had the opportunity to witness how the patients are being counseled by the resident counselors. We did not get to see the whole place as some areas are not accessible by outsider.

Pathological Grief

Dr Tan defined Grief as a highly personal and subjective response to a real, perceived or anticipated loss, whereas Mourning is an intrapsychic process whereby the person adapts to the loss. And Bereavement refers to the fact of loss. When a person experiences complicated grief, health suffers. The psychological outcomes present themselves in depression and anxiety, and worse, suicide ideation. The family relationships suffer too.

Dr Tan used the Bowlby’s Attachment Theory to explain the purpose of grief. It is an instinctive and universal response to separation. Complicated grief may arise as a result of peculiar relationship with the lost person, which may in turn be determined by the nature of attachment with the primary care givers i.e. insecure attachment patterns emanating from parental rejection in childhood. Dr Tan also took us through the Worden (Grief Tasks), Stroebe & Schut (Dual Process Model) as well as Neimeyer’s Meaning/Narrative Reconstruction.

In normal grieving process, the griever may manifest grief in feelings (sadness), physical sensations (breathlessness), cognitions (disbelief), behaviors (sleep disturbance) and spiritual distress (‘Why me?’) Pathological grief may be chronic (excessive in duration), delayed (insufficient emotional reaction at the time of loss), exaggerated (person resorts to maladaptive behavior), masked (symptoms not recognized as related to the loss) & disenfranchised (e.g. EMA)

Dr Tan provided a practical approach to complicated grief. I will have to identify how the grief presents itself. Especially in late bereavement, to assess progress of mourning, identify depression and consider pharmacology. During assessment, I engage the client to talk about the loss – the deceased, the death, social support, chronic stressors (current losses), earlier losses, coping styles as well as any strained interpersonal relationship resulted.

The client needs to be prepared for grief tasks (Worden). After one has accepted the reality of the loss, he/she has to work through the pain of the grief (revive memories of the deceased). The client needs to learn to adjust to an environment in which the deceased is missing and to emotionally relocate the deceased and move on with life.
Client needs to be assured he/she will recover, will be able to continue with life and will find meaning to live on. The deceased will still be remembered even when grieving has stopped. (Permission). Dr Tan provided a list of encouraging narrative reconstruction which I find extremely helpful. The goal is for the client to reconstruct or we collaborate to co-author a coherent and consistent life-script that includes the bereavement, and that will impart resilience as they remake their lives.

Grief & Bereavement

It was a privilege to be under the pupilage of Counseling Guru Yeo. I recalled how my older sister received his potent intervention 20 years ago and went on in life with a changed mindset to give birth to 2 lovely daughters – an unthinkable task due to fear of pain and sight of blood.

Mr Yeo in his wit and wisdom made us see grief and bereavement through his lenses. I valued his free-flow sharing of insights. To him, grief impacts us in an individualistic as well as systemic way. Grief is not time-limited. It mutates from more intense to less intense and sometimes it may never end. It can also trigger previous trauma to cause re-traumatization therefore from less intense to more intense.

Grief is effectively an experiential expression of how one copes with an attachment loss. Such experience essentially signifies one’s capacity to experience (feeling & being) and one’s choice to express such experience or not.

We can be attached to Property, Project or People. Property can be replaced, such as material worth which need not have $ value, or body parts which are tangible. Project is not tangible, such as talent/capability, hope/dream/vision/feeling (in relation to). People is irreplaceable, and it is about the hope and dream we harbour for our family.

Why are some people finding it hard to acknowledge their grief? The scripts they hold determine outcome of grief. ‘Men don’t cry.’ ‘Do not disturb the spirit.’ ‘Move on.’ Delayed grief could be due to dorminant discourse. As a therapist, I need to learn to help client understand and appreciate grief and wait with the client for a time and place when tears will flow. Loss takes on a different meaning at different stages in our life continuum. One thing is certain, as with any kind of loss, there is anger. If I am not sure what to say to a person who is depressed, the golden rule is to NOT say anything. Let him/her talk. I should not be too quick to console. I need to permit EXPRESSION of grief for ‘whatever stays inside stays in.’ Agree with the client that ‘life goes on but it will no longer be the same.’ Say things like, ‘I suppose it’s hard not to feel guilty.’ Or ‘it does seem like you are responsible for the death and that’s why you are feeling guilty.’

Client may not accept the loss but he/she has to live with it by adapting to the reality. The reality is ‘People die, relationships never.’ < To my late father: In life YOU lived for us, in death YOU live in us.> The gist is it is OK to adapt to a life of NO CLOSURE (especially in ambiguous loss). It is permissible to continue to grieve even when it’s perceived as abnormal in the eyes of the normal. My goal will be to help client draw out the strength within them and to look for the resources available to them.

Abuses in Relationships

I signed up for this talk because of my pro-bono work at the Family Transformation & Protection Unit at the Family Court. The clients who walk in to apply for the Personal Protection Order battle with violent significant others. Some just put up with it meekly week after week, year after year and one fine day, they decided enough is enough and came in to exercise their legal right to put a stop the torment.

A very knowledgeable Dr Kong enlightened us on the patterns of abuse. That of two types - Type I is one-off abusive behavior and Type II, persistent.

Usually, violent behaviors are associated with psychiatric illnesses such as depression and grief. There is also the likelihood of Type II leading to Borderline Personality Disorder. Sadistic abuses are hurled by either Borderline or Narcissistic Personality Disorder.

Dr Kong explained abusive behaviors by exploring the Oedipus Complex in Freudian psychoanalysis. It refers to the stage of psychosexual development in childhood where children of both sexes regard their father as an adversary and competitor for the exclusive love of their mother. In psychodynamics, Object Relations theory is the idea that the ego-self exists only in relation to other objects (foundational relatedness with mother specifically), which may be external or internal. The internal objects (e.g. past events or experiences) are internalized versions of external objects (significant others), primarily formed from early interactions with the parents. There are three fundamental "affects" that can exist between the self and the other - attachment, frustration, and rejection. These affects are universal emotional states that are major building blocks of the personality.

It is essential that children experience connectedness with their parents. A secured and constant attachment will give rise to a healthy internal representation. The experience of deprivation during childhood can lead to stress in life. Insecured attachment results in Pre-occupied Anxiety (‘Where are you going, mum?’), Dismissive-Avoidant (‘In order to avoid being hurt, I will dismiss you first.’) & Fearful-Avoidant (Want to avoid yet fearful you will leave.) Ultimately, a good-enough parent will provide a secured base.

Object Constancy is the goal in promoting ideal psychosexual development. When good object is being internalized, there is no place for asking, ‘Where were you?’ nor ‘It’s my fault, you left because I didn’t behave right.’ During intervention, allow appropriate verbalizations – ‘I am angry.’ ‘I deserved to be loved.’

Counselling at the FSC

Mr Ho worked for the FSC previously and with input from Colin and Nancy who are currently attached to the FSC, we were enlightened on counseling at FSC.

FSC is a neighbourhood-based centre runs by a voluntary welfare organization. It is accessible by the community for family resources. As the FSC is limited by boundary, the residence of the needy person has to be established upon contact to avoid waste of time. An Information and referral (I&R) form is to be filled and the person in need will then be linked to appropriate services.

Apart from Case Work and Counseling, FSC’s other core programmes are Preventive & Developmental Programme (PDP) as well as Outreach to Elderly, Adult, Children & Youth.

Counseling in FSC setting is handled by a Case Worker generally, however, in some FSC, counselors are appointed to handle counseling issues exclusively. In the case of Case Worker who is assigned cases, the first contact will determine if it is a one-off case for consultation purpose. Otherwise, it will be referred as an Open Case and it is normally contract for a 5-session follow-up. Case Worker functions more like a Social Worker. Counseling at FSC involves administrative assistance, home visitation, etc. Monthly or quarterly reports are compiled for evaluation purposes. In a FSC setting, case conference limits confidentiality as the latter is extended to agency staff. It is short of saying NO confidentiality.

Counseling in FSC is challenging. Colin reported 60 active cases in hand. I wonder if actual counseling intervention is short-changed or effectively addressed when the workload is heavy. On the other hand, such diverse setting provides perks as the Case Worker/Counselor is exposed to varied issues and options available to resolve them.

Mr Ho conducted a Live Demo of interviewing a client with a Reflecting Team of counselors which can be conducted in a FSC setting. I learnt the Relaxation Technique used and how he helped the client processed her thoughts, even the significance of her tears: ‘If the tear has a voice, what would the tears be saying to you?’

Counselling in Addiction Disorders

Dr Yeo has such sense of humor one cannot help but overlook the facts he is trying to present. That was precisely what took place on a few occasions during lecture because some coursemates got him to repeat some facts a couple of times.

There are two broad concepts of addiction according to Dr Yeo. Addicts are viewed as bad criminals and must be punished under the Social model while the Medical model deem addicts sick and therefore need to be treated.

I benefited from Dr Yeo’s painstaking description of the different types of substance abuse. For the first time, I heard of Shyabu, Adam, Yaba, FRY and Ketamine. During assessment of drug addiction, check for poly-drug abuse, look for coexisting diagnosis, depression, anxiety disorder, psychosis and underlying personality disorder.

Medical detoxification is the first stage of addiction treatment. It safely manages the physical symptoms of withdrawal but does little to change the long-term drug use.

Motivation is the strongest factor in facilitating change in an addict. Counselor has to adopt Rogerian concepts of empathy, warmth and genuineness. Roll with the resistance and refrain from imposing and labeling. Patient is offered different perceptions and self-efficacy – You CAN do it. Each slip or relapse is viewed as one step closer to recovery. (An addict may relapse 4 times before permanent change.)

Dr Yeo advocated Confrontational Models in Group Psychotherapy dopted in Alcoholic Anonymous & Narcotic Anonymous and ‘Hot Seat’ (Minnesotta Model). Such models may not be suitable for patients who are depressed, anxious or have low self esteem.

The patient goes through stages of change and the therapist’s tasks will be:

- Precontemplation stage (To raise doubt, perception of risk)
- Contemplation (Tip the balance, evoke reason tochange)
- Determination (Help choose best course of action)
- Action (Help take steps to change)
- Maintenance ( Identify and use strategies to prevent relapse)
- Relapse (Help renew process of contemplation, determination & action without demoralization of being stuck)

Non-drug interventions for addiction - counseling and other behavioral therapies - that help will be Replacing Drug Using Activities, Drug Resistance Skills, Motivation, Problem Solving Skills and Interpersonal Relationships.

I am to identify trigger points, cue avoidance, offer alternate forms of stress relief – exercise, pilates and meditation. Time freed up when trying to quit addiction has to be filled up with alternate interests and a healthier lifestyle. I will also facilitate family intervention by helping patient set goal and earn trust of family members. There must be financial accountability. The issue of co-dependency will be looked into to ensure the patient is not being empowered to carry on with addiction.

Counselling at Student Care Service

Mrs Tan looked more like a teacher than a counselor but she was also a very creative facilitator and I was impressed.

The ice-breaker game she got us to engage in was rather intense in that within ten minutes or so we were to interact and exchange worldviews to half of our peers. Some information we disclosed were rather personal but our group has over the months become more familiar with one another. It did not mean a greater knowledge of one another. So this game actually got us to talk heart-to-heart briefly. A nice way to melt the ice!

Mrs Tan briefed us on Student Care Service (SCC) & School-based Counseling (SBC). The SCC was actually set up by VWO since 1978 to help maximize the students’ potential. It has evolved from providing just School Social Work (operating within school’s premises). A list of other services such as Educational Psychological Services, Casework & Family Counseling, Guidance Programme etc are also available. The main focus will be on the students in all aspects: educational, financial, emotional, relational, behavioral & developmental.

School-based Counseling takes place when a social worker meets up with students referred by the school, parents, other students or selves to work on presenting problems in individual or family counseling sessions. The general goal will be to enhance the functioning of these students through enabling the students and their family to cope with or resolve problems experienced by students. The psychological components that of perception of counseling, expectations of school and parents as well as accountability will determine the successfully running of a SBC set up.

Mrs Tan shared some useful skills and techniques in SBC. De-triangulation will ensure that the counselor’s focus is on the student only. And during counseling session, exception questions will be ideal when addressing students (age factor). Clarification and summarization of statements will also go a long way in bridging the relationship. The students’ faith and hope will be raised according to the expertise of the counselor. The relationship between the counselor and student plays an equally important role as the support system the student has (family etc and his or her own internal resources included).

Alas, we were not able to go in-depth into how to deal with critical presenting issues such as Rape/Molest, Under-aged sex/pregnancy, Beyond Parental Control, gang involvement and runway teens. It will be ideal to have a legally-trained facilitator to walk us through the legal processes and procedures.

Counselling the Children

To Dr Fung, children’s mental health is more than just absence of mental illness. The children must feel good about themselves, relate well with their significant others and caregivers and peers. They are also protected.

There are difficulties in detecting mental health problem because children may not complain or they may have difficulties talking about feelings. Their acting out are seen as naughty and sometimes withdrawn behaviour is missed. And most times parents are having problems.

About 10% of children have some form of mental health disorders. Children may suffer from different types of mental health problems in the form of disturbances in development, feelings, behaviour or relationships. Behavioural disorders are more common than emotional disorders. Depression is rare in children. Mental health problems in children are associated with multiple risk factors, the most significant being lower intellectual ability and parents being single, divorced, separated, widowed or deceased.

When counseling a child, talk about culturally appropriate topics. Explain to the child the purpose of counseling while building rapport with him/her. With some understanding of the developmental phase of the child, the needs are being assessed. I will learn the likes and dislikes, strength and weaknesses of the child. By being observant I engage with the child and establish the therapeutic alliance.

When talking to the children, my sentences have to be short, clear and simple. My tone has to be calm and reassuring. My words should ideally be positive. It will help to use open questions and rephrase if necessary. One good technique to ensure comprehension will be to ask the child to repeat rather than ask ‘Do you understand?’ I need to give time for the child to speak before starting new ideas or feelings.

When the children don’t want to talk, play and art therapy should then be used. Let the child do his own activities in my presence. Listen to what he says verbally and non-verbally. Acknowledge with statements of understanding before giving advice. Validate the child’s feeling. Let the child know how I feel and then provide supportive therapy. Medical treatment should flow from diagnostic formulation of psychopathology from a developmental perspective.

Mindfulness-Based Cognitive Therapy & ACT

Dr Tan is a Professor of Psychology at the Fuller Theological Seminary. He shared an article written by him that covers the appropriate and ethical use of prayer including inner healing prayer, and Scripture in a Christian approach to cognitive-behavioral (CBT). Expanded CBT now includes Mindfulness-Based Cognitive Therapy (MBCT), Acceptance and Commitment Therapy (ACT), and Dialectical Behavior Therapy.

Unlike CBT, there is little emphasis in MBCT on changing the content of thoughts; rather, the emphasis is on changing awareness of and relationship to thoughts, feelings, and bodily sensations. Aspects of CBT included in MBCT are primarily those designed to facilitate ‘decentered’ views such as ‘Thoughts are not facts’ and ‘I am not my thoughts.’ Clients are taught to disengage from habitual (‘automatic’) dysfunctional cognitive routines, in particular depression-related ruminative thought patterns, as a way to reduce future risk of relapse and recurrence of depression. MBCT was specifically designed for remitted patients.

ACT is a functional contextual intervention approach based on Relational Frame Theory, which views human suffering as originating in psychological inflexibility fostered by cognitive fusion and experiential avoidance. In the context of a therapeutic relationship, ACT brings direct contingencies and indirect verbal processes to bear on the experiential establishment of greater psychological flexibility through 6 core processes: -

1. Acceptance
2. Cognitive Defusion
3. Being Present
4. Self as Context: A transcendent sense of Self
5. Values
6. Committed Action

ACT is unusual in that it is linked to a comprehensive active basic research program on the nature of human language and cognition.

Reaching the Hearts of Teens

I embarked on a 8-weekly workshops on Reaching the Hearts of Teens purely to look at teens’ issues from the spiritual perspective. Personally, I believe no family reaches a healthy status by its own power. There is a spiritual dimension that cannot be minimized.

It was a good turn-out of parents with only one teenager among us. During the first workshop I observed a strong sense of desperation in most parents. There was fear and tension when it comes to relating to our teens. The objective of the workshops was to replace the parents’ fear with confidence and tension with trust.

Teen rebellion was referred to as relational tension by the Ezzos. Such tension is a result of our fallen humanity – it’s the absence of wisdom ruling the moment. (Proverbs 1:7, 26:12) Teenagers tend to flee from relationships, which comes out in the form of rebellion. Hormones are unquestionably at work during the teen years. They may affect the human body, but not the human heart. The ultimate source of the tension is a deficiency in the parent/teen relationship. In struggling families, teens seek independence from childhood structures of growth and development as well as unhealthy relationships (e.g. divorce) existing in the families. Defiance is fundamentally a heart issue. The bottom line is that it’s a moral choice. There is within every human a natural selfishness that makes us want to defy anyone or anything that’s going to take away our self-governance.

Some of the tests we did:

1. The health of individual family profile between parents and individual teenager. As my teens have matured to a good extent, I shared a rather healthy parent-teen relationship with them, with minor problems.

2. The Primary Love Languages of parents and teens. I found out that I treasure quality time among Encouraging Words, Acts of Service, Gift-giving & Physical Touch. My sons thrive well when they receive Encouraging Words from their parents.

I learnt much from attending the workshops which I applied rather immediately on the clients I was seeing. Personally I like the Ten-Talk Rule on seeking full attention when our teens ask for it. When they absolutely and immediately need my attention, they can say, ‘Mum, I need to talk with you, and this is a ten-talk.’ (On a scale of one to ten, ten being most urgent.)

Counselling the Mentally Ill

As always, Dr Tan came across as a compassionate person. He acknowledged the late-comers by saying things that made them feel comfortable and self-accepting. I felt blessed to be associated with the top psychiatrist in Singapore and to be a student of his.

Psychotherapy is the systematic use of a human relationship for therapeutic purposes of alleviating emotional distress by effecting enduring changes in a client’s feeling, thinking and behaviours.’ - Strupp 1986

Time Limited Psychotherapy is not suitable for long-standing personality disorders, chronic and persistent mental illnesses (such as schizophrenia and bipolar disorder. CBT has been demonstrated to be effective for Depression, Anxiety Spectrum Disorders, Eating Disorders, Sexual Disorders and Substance Abuse.

I learnt different techniques to solicit information from the mentally ill clients who may be vague or give monosyllabic replies and some resistance to boot. I need to find a balance between letting the patient tell his story in his own words and in obtaining information from him using Opening Techniques. Clarification Techniques (Patient-Centered) are used for Specification, Checking Symptoms, Probing (for delusion), Interrelation (for disordered thinking) and Summarizing (for psychotic clients).

I can also choose the Interviewer Directed Steering Techniques at some points – Continuation, Echoing, Curbing (irrelevance) & Transition (smooth or abrupt )

In dealing with Resistance, we use the techniques of Acceptance, Confrontation, Looping, Exaggeration and Induced Bragging.

It was helpful that the techniques were illustrated with transcripts of dialogues between therapist and client.

Boundary & Legal Issues in Counselling Practice

Dr Tan commented that therapist and client relationship should be asymmetrical, i.e. one way focus on client and his/her needs. It should not be 2-way or dual as in social relationship where there is no boundary. A therapist should maintain objectivity, neutrality and abstinence.

Dr Tan touched on the non-sexual boundary crossings. Although self-disclosure used to be an absolute prohibition, it becomes essential when disclosure of therapist’s health condition, for e.g., may determine the duration of sessions.

Confidentiality may be breached if client’s suicidal, homicidal or when the court demands for it. And confidentiality of clinical information about clients remains ethically in force after the death of client and therapist. (This is new to me!)

Tarasoff Principle - When a psychotherapist determines that his patient represents a serious danger of violence to another, he incurs an obligation to use reasonable care to protect the intended victim against such danger. The discharge of such duty may call for the therapist to warn the intended victim or others likely to apprise the victim of the danger, to notify the police, or to take whatever other steps are reasonably necessary under the circumstances. - Judge Tabrinen 1976

(Protective Privilege ends when public peril begins – Tarasoff vs Regents 1976)

To Give Up or Not to Give Up

Artwork (c)2006, www.psychotherapy.net

Introduction

In Redecision Therapy (RT) the client experiences the child part of self and creates fantasy scenes. By integrating the cognitive framework of Transactional Analysis (TA) Theory (Berne, 1958) and affective principles and processes of Gestalt Theory (Perls, 1951), client can be helped to safely give up the constricting decisions he made in childhood. (Mary & Robert Goulding, 1979)

< To Give Up or Not To Give Up >

Marie, 37, had filed for divorce but was troubled by her own decision. Prior to her legal action, Marie noticed her husband, Judd (49), a sales executive, behaving strangely, such as bringing his handphone with him into the shower and returning home in the wee hours. She had a nasty feeling that her husband had snapped back to his former adulterous living again.
Marie was incensed when Judd confessed that he was madly in love with a married Chinese colleague. When confronted, Judd rebutted coldly, “you are no longer sexually appealing to me, I have no choice but to find someone else.” [Judd played the PROSECUTOR role in Mind Game– ‘Look what you have done to me.’ – You are not OK.] (Berne, 1964) Marie was devastated and in her words, “it felt like a thunderbolt.”

Marie had been losing sleep over Judd’s increasing absence from home. Most nights she would cry herself to sleep. Her demands for his attention were reciprocated with more hostility. Marie became forgetful and experienced mood-swings. Ironically, in the quiet of the nights, beneath the torments brought about by her husband (the first and only man in her life), she still yearned for his love and touch. She felt desperate, not knowing how to continue in a love-less marriage.
Even after she had filed for divorce, Marie would still pine for affectionate messages from Judd. He had indicated in one of his messages, ‘perhaps it’s good for us to go separate way now. But who knows, I may come back for you someday and we can re-marry. Just don’t let any man touch you until then.’ [Playing the role of RESCUER – ‘What would you do without me?’ - You are not OK.] Ironically, Marie was both infuriated by his selfish thoughts and gladden by his show of jealousy.

Case history - Past problems

In the first eleven years of their marriage, to the external world, theirs was the ideal picture of a perfect family— loving and contented parents with a happy child. Marie, being 12 years younger than Judd, looked up to him as a decent and loving partner. On the other hand as Marie is more resourceful and stable in her income, Judd deferred every financial decision to her. She was seen as a confident and decisive person, adored by her late mother and well-respected by her students and friends.
The year after Marie’s parents passed away, i.e., 2002, Judd began a series of extra-marital affairs. The latter was remorseful after the 1st affair and promised to stay faithful. The delighted Marie bought him a car. In December 2005, Marie found out Judd was seeing 4 women (2 Philippinas & 2 Malay ladies). Marie was indignant and perplexed by the drastic change in Judd. Their relationship deteriorated to cold wars.
Heart-broken and depressed, Marie popped in 30 panadols in an attempt to end her life. Judd stopped their only son (16), Jayden, from seeking help and threatened to punch the latter.

On another occasion Jayden saw his father accessing pornography websites and confronted him. Judd was upset and both ended up in a heated argument. Marie was disgusted by the faulty role-modelling of Judd especially when the latter would approach the son and licked his face. Jayden’s school grades had dived. The class teacher had commented that Jayden looked downcast in school.

Therapeutic Contracts

Eric Berne (1966) defined a TA contract as ‘an explicit bilateral commitment to a well-defined course of action.’ TA assumes that people have the capacity to think and make decisions. As the Redecision Therapist, I helped Marie identify what she wanted (Therapeutic Contract transcript - Appendix 3) and how she could use her resources to achieve her goals. It is a contract for change Marie made with herself after she had closed her escape hatches such as taking her own life or harming others. Her escape hatches were closed by Adult decisions: ‘to live and take care of myself’ ‘and let others live and take care of themselves.’

Appendix 3

THERAPEUTIC CONTRACT TRANSCRIPT

Redecision Therapist: What do you want to change?
Marie: I am unable to stay focus in my work.
RT: What specifically do you want to change now?
M: I want to get out of the sadness that plagues me daily.
(M is seeking Symptomatic Relief.)
RT: What needs to happen for you to make this change?
M: I need to give up clinging on to the rotten marriage and move on.
(M is seeking Script Cure – to move permanently and substantially out of SCRIPT patterns.)
RT: What are you willing to do in order to make this change?
M: I will talk about my problems, experiences and memories to gain an understanding of my thoughts, feelings and behaviours in this meaningless relationship that is heading for a divorce. (Soft Contract)
RT: How might you sabotage yourself?
M: By telling myself that `I am not good enough’ or `I can’t survive without Judd.’
RT: How will you and I know when you have made the change?
M: When I report to you that I am no longer feeling sad.
(James, 1976)

Treatment Plan for Redecision Therapy

Transactional Analysis

In RT, the primary question is: What early childhood decisions are causing problems today. As Eric Berne first noted, a client’s current problem is often the result of injunctions and decisions stemming from childhood.
A useful way of diagnosing Marie was to assess her ego-states. Ego-states, in Berne’s definition of the term, were the building blocks of the Structure of Personality (Berne, 1961). Parent and Child were both echoes of the past. Adult was a response to the here-and-now, using the person’s grown-up resources. All three states entailed thinking, feeling and behaviours. (Stewart & Joines, 2003) RT seeks to re-programme the Parent, de-contaminate the Adult and de-confuse the Child. What ego-state strengths can Marie muster to make contractual changes and how well can Marie sustain these changes once they are made?

When Judd criticized Marie for not being sexually appealing enough, the latter went on a slimming programme to look shapely. But when Judd commented she looked too thin, she regained her weight right away. [Playing the role of VICTIM - ‘Poor me.’ – I am not OK.] - Marie paid more attention to her own faults and flaws (coming from her Critical Parent ego) than to her assets and successes. Marie needed to learn to nurture herself (Nurturing Parent ego) rather than self-criticized. One of her contracts was to learn to love herself wisely by doing things that would promote personal growth. To model positive nurturing, I must give Marie positive strokes for growth or change, as well as for ‘just being’.
Marie’s Adult, or thinking part, had been contaminated. A Parental contamination stood in the way of achieving a contract, it needed to be resolved. Marie was very close to her mother and was well-compensated by her mother’s love so much so she did not feel the need for fatherly love. For years, her father was aggressive and violent towards her mother and her. He broadcasted his affairs with other women without blinking his eyes. Marie’s mother was deeply upset but did not protest, instead accepted it as ‘fate’.

However, the young Marie had often heard her mother sobbing uncontrollably in the middle of the night. In the day her mother would escape to the gambling den with Marie in tow. That suited Marie fine as she resented her father and would not stay a minute longer in his presence. On the other hand, she felt sorry for her mother and vowed in her heart to do anything to please her, even at the expense of her own happiness and convenience.

There seemed a Structural Pathology of double contamination from the Parent (P) and the Child (C) ego-states. Marie re-played a Parental Slogan, agreed to it with an Adapted (Compliant) Child belief, and mistook both for reality:

Mother (P): ‘Resign to your fate. Hang in there. Be pleasing and you will be ok.’ Paired with
Marie (C): ‘Like mum, I’ll keep my anger and resentment to myself. I will make Mum happy by not giving up.’

(2nd Order Structural Analysis – Appendix not available)


Script Analysis

Berne defined a Script as a personal life plan decided upon by each individual at an early age; in respect of the interpretation of external events. (Steiner, 1974) Two-chair technique was used to conduct the Script Questionnaire (Appendix 5) to elicit drivers and injunctions from her parents.

Appendix 5

Script Questionnaire (Jeff & Margaret White)

(A)

Set up 2 chairs, one for Marie and one for her parent (mother) figure:

Mother: `I am most happy with you when you stay close to me. (Driver)

* * *

Marie: When I was little, my mother was most upset when I give up trying. (Injunction)

Marie: When I saw mother upset, I felt guilty, sad and remorseful.

Marie: When I felt this way, I kept quiet and sulked.

Marie: (The theme of my mother’s life) - She suffered in silence.


(B)

Set up 2 chairs, one for Marie and one for her parent (father) figure:

Father: `I am most happy with you when you obey. (Driver)

* * *

Marie: When I was little, my father was most upset when I made mistakes. (Injunction)

Marie: When I saw father upset, I felt frightened and resentful.

Marie: When I felt this way, I stayed away from my father.

Marie: (The theme of my father’s life) - He was chauvinistic and selfish.


Marie’s script matrix - Appendix 6)

Drivers –
From father: Be perfect/Try Hard From mother: Be close/Be pleasing
Drivers come from the Parent ego-states of our parents. Marie’s father flared up each time Marie made a mistake. She would take cover by following her mother to the gambling den. She knew by staying close to mother made the latter happy.

Injunctions –
From father: Don’t express/Don’t be close/Don’t be important

From mother: Don’t give up/Don’t be you/Don’t think

Whenever her father went into a rage, Marie would be reduced to tears (The Adapted Child). She would be prohibited from explaining herself. Marie found herself also being restricted by her mother’s injunctions of ‘Don’t think, Don’t be you and Don’t give up’ which came from a threatened position. Such injunctions stifled and confused Marie in her sense of judgment and decision-making. In order for Marie to be free from the injunctions, she must be able to make a new Decision.

Rackets Analysis

Rackets are repetitions of which were stroked in the past. They are expressed each time a real feeling is about to emerge. (English, 1972) Rackets usually come from early child decisions. (Racket System - Appendix 7)


Appendix 7

Marie’s Racket System


Script Belief / Feelings:

Self - I am unlovable. (Core)

Husband goes for other women. (Supporting)

Others - Men in general sexually `objectified’ women. But they
would return to their spouses. (Core)

Men visit the prostitutes to gratify their sexual need
only. (Supporting)

Quality of life - Life is harsh and miserable. (Core)
I am not good enough. I will keep trying. (Supporting)

Rackety Displays:

Observable Behaviours - Unable to focus at work. Sulk. Insomnia.

Reported Internal Experiences - Heart palpitations/loss of appetite/feeling miserable/loss of zeal

Fantasies - Son would remain single to take care of her / Husband would return to re-marry her / Husband would pass on STD to her

Reinforcing Memories: - Marie sleeps with her son and cries herself to sleep/Re-reads Judd’s sms-es

Permitted Feeling: Sadness and Grief

Repressed Feelings: Resentment and Anger


Marie’s racket feeling was scared (SCARED) and sadness (SAD) and prohibited feeling was resentment and anger (MAD).
The racket and prohibited feelings were displayed during a session. Marie recalled one of the many selfish requests Judd made. It was also at this juncture she gave out a Gallows Laughter to reinforce her pathology (overwhelming sense of sadness).

RT: What was the laughter about?
Marie: He pleaded with me to go through the vaginoplasty surgery to gratify his sexual desire.
RT: You were tickled by his proposal?
Marie (in exasperation): “I kept quiet but wondered what next?!”

Marie began to realize even if she were to go ahead with the surgery, she might not be able to stop Judd from seeing other women. After I had gone over the Racket Analysis with her, she became acutely aware of feeling and behaviour patterns.

Marie (relented in tears): “I resented him for treating me as a sexual object.” (She was made to repeat thrice in an emphatic tone.)


Marie’s Impasse
“I want to get out of my unhappy marriage.” “But I don’t really want to give him up.”

Gouldings emphasized Perls’ belief that when a client is ‘STUCK’ with a problem, this indicates that two parts of his personality is pushing in opposite directions with equal force. The net result of the above led Marie to nowhere in spite using a great deal of energy. The resolution to treat the above IMPASSE was to help Marie make a REDECISION.

Marie had a second degree Impasse with Impasse present within her Child (C2). There was subconscious conflict exists between P1 and C1. She was modeled ‘not to give up’ by her mother despite having miserable marital relationship. She complied with the injunctions of her parents from her Child as her Early Decision was “I am not worthy. I will do whatever you say. I will never give up trying to please you.”

Two-Chair technique (Early Scene Work)

Redecision had to be made within the Free Child Ego State of Marie’s C2
by A1 between the young Marie’s Child (C1) and the fantasized Child of Marie’s mother that gave the injunction. Using the two-chair technique, Marie was facilitated to go back to the early scene (to the scene when the young Marie was lying in bed next to her sobbing mother) so that she could contact her unexpressed feelings and sought permission to break her impasse - ‘to give up trying and move on’.

Marie (the child): “Mum, it hurts to see you cry.”
RT: “Be your mother and give permission.”
(Mother): “You may give up when it hurts too much, dear.”
Marie: “I am hurt too much. I want to give up the rotten marriage.” “I can give up. I can move on.”
(At this juncture, Marie remained silent for a full minute. There was no shedding of tears and in her words, ‘I felt a brick lifted off my chest.’) (Symptomatic Relief)

During Adult Debriefing, Marie was helped to anchor the scene of resolution and make adult plan for herself to feel, think and do differently about her future. (Moving towards the Script Cure)

Conclusion

Redecision is a beginning rather than an ending. Marie’s contracts to change were achieved in the brief therapy. Her new found sense of control was obvious when she moved out of her matrimonial home with her son even before her divorce was made absolute. The therapy had empowered her to begin a new and happy Script without Judd.

It is OK to Give Up when it Hurts too much.


(1798 words)


References


Berne, E. (1958). Transactional Analysis: A new and effective method of group therapy. American Journal of Psychotherapy, 12, 735-43.


Berne, E. (1961). Transactional Analysis in Psychotherapy. New York : Grove Press

Berne, E. (1964). Games People Play. New York : Random House Ballantine Book


James, M., & Jongeward, D. (1978). Born to win. Boston : Signet


Goulding M.M. & Goulding R.L. (1997). Changing Lives through
Redecision Therapy. New York : Grove Press


Perls, F. (1951). Gestalt Therapy: Excitement and Growth in the Human Personality ISBN 0-939266-24-5



Steiner, C. (1974). Scripts People Live: Transactional Analysis of Life Scripts. New york : Grove Press


Stewart, I., & Joines, V. (2003). TA Today. England : Russell Press

Counseling Patients with Cancer

Artwork (c)2006, www.psychotherapy.net

Dr Koh gave a run-down of statistical and informational update on curable and incurable cancers. The graphic presentation was a little difficult to stomach. Although it was brief, the impression it created has since stayed on in the mind. His ultimate message to us all was, ‘Early detection saves lives!’ The tumor size, symptom control and quality of life will determine the outcome of treatment. Some common screenings that normal and healthy people can go for are mammogram, Hepatitis B Screening, Pap Smear, Fecal Occult blood test.

It is well documented that counseling and psychotherapy can improve quality of life for cancer patients. Cancer and cancer treatments can affect a person’s:
 body image and appearance
 energy levels
 physical, social, and mental functioning
 intimate relationships and sexuality.
The goal of counseling and psychotherapy is to help patients make the functional, emotional, and spiritual adjustments necessary to maintain their quality of life.

A wide variety of psychological interventions are available to the cancer patient, including:
σ educational cancer-related counseling
σ individual supportive psychotherapy
σ cognitive behavioral therapy
σ group therapy and/or cancer support groups.
In my counseling with cancer or terminally ill patients, good communication skill is very important. Patients often have filtered information. It is important that I identify and acknowledge their emotions, find out what they already know and what they want to know. When giving information, I will need to check that the language used is right, i.e., word used must have the same meaning to both.
I wished Dr Koh would elaborate on how Cognitive behavioral therapy (CBT) could help the cancer patient. But I guess as a medical doctor he focused on how the counselors could attend to the patients in an all-rounded manner. I went on line to search for related article to understand how CBT can be used on cancer patients. (http://www.cancerline.com/cancerlinehcp/9898_21550_0_0_0.aspx? Extracted on 25 June, 2007)

CBT was initially developed by Aaron T. Beck, MD to treat depression and has been validated as an effective psychotherapy for patients with cancer. CBT is based on the assumption that depression and anxiety arise from negative internal dialogue, or “self-talk.” By replacing negative dialogue with positive self-talk, patients feel and act more positively, even in the face of life-threatening illness.

Central to CBT is the theory that the individual has control over his or her thoughts and has the power to modify feelings and behavior. The cognitive behavioral therapist helps the patient to take specific steps to do this.

1. Actively identify negative thoughts as they occur.
2. Document the negative thought.
3. Correlate it with related events.
4. Identify the type of faulty thinking.
5. Replace the negative thought with more a realistic—and positive—interpretation of events.

Studies have shown that CBT helps to quickly alleviate stress, depression and anxiety in patients with cancer. CBT reduced the prevalence of moderate depression in women diagnosed with stage 0–II breast cancer. Women with early stage breast cancer who underwent CBT experienced less anxiety and disruption of family relationships.

From the same website, I learnt Relaxation Techniques that have been proven helpful in bringing down the anxiety level of patients. Relaxation has been defined as a “state of consciousness characterized by feelings of peace, and release from tension, anxiety and fear.”

In the 1970’s Herbert Benson, MD began recommending a simple form of meditation to his patients to elicit the “relaxation response.” This response moderates sympathetic arousal and produces marked health benefits, resulting in:

 decreased heart rate and blood pressure
 lowered lipid levels
 decreased levels of circulating stress hormones
 improved immune functioning

There are a number of techniques that patients can use to induce relaxation, but they possess underlying common factors. Some of the most common methods are:

guided imagery or visualization
progressive muscle relaxation
meditation

Studies do not show benefits of one relaxation technique over another.

Research does show that relaxation is an effective adjunctive therapy to help cancer patients:

 self-regulate feelings of distress
 reduce cancer-related and neuropathic pain
 improve mood disorders
 lessen fatigue

There is also evidence that relaxation improves post-surgical outcomes, such as length of stay and recovery time.

"To talk sometimes, to listen often, to understand always.
To cure sometimes, to relieve often, to comfort always.” - Pierre Ambrose

Post Traumatic Stress Disorder (PTSD)

Artwork (c)2006, www.psychotherapy.net


It was a warm Sunday at Thong Sia. I had a hearty meal with family at Sushi Tei, Paragon before class. One of the air-cons was down but I was strategically seated where the working air-con faithfully blew at me. How blessed! Soon papers and hands were swaying to keep one awake… The ‘traumatized’ ones kept nodding as Prof Bates continued.

Wow, Swinburne University was rated top Victorian university for The Educational Experience (Source: The Good Universities Guide, 2007.) We have been informed previously that the university was ranked 4th out of 39 universities in Australia for Learning and Teaching Quality (Source: Department of Science, Education and Training (DEST), 2005) I have made the right choice and now proud indeed to be associated with the University! < LET’S GET ON WITH IT. >

I was all ears throughout Prof Bates’ lecture because I am currently seeing a client diagnosed and medicated for PTSD. I have seen her once todate and have provided her (Applied) education about trauma and PTSD. It was indeed timely to be further equipped by Prof Bates!

My client (K) suffered sleepless nights for 3 weeks before she sought psychiatrist help. A new colleague (M) she was closed to for 3 months had jumped to her death after sms-ing her the night before. K is an only child. She became very agitated to loud noises and fearful in darkness. She wept whenever she thought of M.

There seemed to be a psychological trauma K is suffering. It is an injury to her mind and inherent processes and functions (including identity and sense of self). Her assumptions about the world have been shattered and must be rebuilt.

In DSM-IV-TR the range of event that became a stressor for K was neither Directly Exposured to the tragedy nor Witnessed the Event. It was an Event Learnt About of the sudden loss of a close colleague. As a stress syndrome PTSD is defined as a psycho-biologically driven organismic function of adaptation to abnormal excessive or extreme stressor events that tax individual coping resources.

K consistently re-experienced ruminations of the tragic news. She kept thinking of the days before the fatal plunge. Whenever she read of news pertaining to suicide, she would bring it up to the parents. Her parents were upset by her ruminations. K had recurrent and distressing dreams aligned with death. Her symptoms of hyper-arousal include: Difficulty falling or staying asleep, irritability with noise, hyper-vigilance (have to sleep with the lights on).

K’s sense of self, others and the world have undergone a drastic shift. She needs strategies for developing self-awareness to restore herself to the previous functioning:

1. Recounting the specific episodes (the ABC model)
2. Exploring shifts in affect 3. Free association 4. Using Imagery
5. Role-plays 6. Symptom induction 7. Discussion of the worst case scenario
8. Look for thoughts that might explain feelings 9. Dysfunctional Thought Records 10. Homework

K is now being medicated (I am a believer in pharmacotherapies) and she will be offered Phased Treatment of PTSD. There will be symptom management of low tolerance level of noise using relaxation techniques. Trauma focused work (imaginal exposure in K’s case) as well as cognitive restructuring (grief and guilt, etc) will be followed up. We will also collaborate and work on Relapse prevention and maintenance of treatment.

A snapshot of treatment strategies for K as proposed by Prof Bates

1. Writing Therapy (Pennebacker) to develop a trauma narrative.

K will be asked to describe the traumatic event in an open ended manner. I will enquire about the details of the event to ensure inclusion of:

- physiological and emotional reactions at the time.
- choice points and actions taken before, during and after
- meanings attached to the event, own reactions or behaviours
- responses of others during and after
- cues that trigger memories
- specific symptoms of re-experiencing, avoidance, arousal
- difficulties in relationships, academic or work since the event

Confronting the traumatic memories has to be done gradually and safely. Research shows too few practitioners offer effective interventions esp exposure.

2. Imaginal Exposure (IE)

IE is graded, prolonged, repeated, pace, collaborative and functional. K needs to know emotional processing helps to organize the memory and process the trauma and that thinking about it is not dangerous. She needs to be repeatedly exposed to the trauma and in the long run it will lower her anxiety and disconfirm beliefs. Exposure enhances her sense of self-control and personal competence.

Before I conduct IE on K, I need to be aware if she has a history of impulsivity or psychosis. There are 3 primary targets for exposure:

1. The memory of the trauma
2. Other internal and external cues that trigger anxiety and re-experiencing
3. Situations that are avoided (The workplace)

Conducting IE:

1st step:

1. Client initially relaxes and `book ends’ are established.
2. Client then tells the story of the trauma (which is tape recorded)
3. The therapist acts as guide asking questions to a) focus on details (e.g. sights, sounds, smells and other sensory experiences) b) ensure all significant details of the story are included and nothing is avoided.
4. Periodically rate client’s distress (0 to 10)

2nd step:

1. Client listens to tape recording of the story again and again closing eyes and attempting to relive it
2. Exposure should continue until anxiety ratings drop at least 50%
3. If trauma is complex, story needs to be broken into segments and tell across several sessions.
4. Exposure must proceed until anxiety drops because a) terminating when distressed strengthens the distress b) decreasing anxiety for the first time is a powerful experience that contradicts fears of being overwhelmed by anxiety and provides motivation for future work.

3rd step:

1. Once client has habituated to the tape of the trauma story at the clinic, client listens to the tape as homework.
2. At least 45 mins per day is recommended to supplement writing the trauma narrative.
3. Anxiety specific cues can be included (loud noises, car horns)

3. Cognitive Restructuring

K was feeling guilty about not being able to detect depression in M. She wished she had spent more time with her. In PTSD, cognitive restructuring targets the client’s distorted thoughts, assumptions and beliefs associated with the trauma.

K said, ‘What happened was my fault.’

Techniques:
• Examine knowledge and choices available to K at the time.
• Double standard technique – would she blame a friend in a similar situation?
• Construct pie chart assigning responsibility to all relevant parties
• Practice self-forgiveness


K thinks ‘The world is unpredictable.’

Techniques:
 List advantages/disadvantages of the belief.
 List areas of K’s life where she has some control and rate degree of control
 Cost/benefits of specific attempts at control
 Record behaviours producing predicted outcomes
 Engage in behaviours with predictable outcomes
 Accept that some events are unpredictable

K feels that she is incompetent and that’s why M did not trust her enough to share her problems before she jumped to her death.

Techniques:
 Examine evidence of competence in K’s daily life
 Examine unreasonable expectations of competence in extreme and unusual circumstances
 Keep a log of competent coping
 Graded task assignment

K is also experiencing defensiveness when she is relating to people. ‘Other people cannot be trusted. M said one thing but did another.’

Techniques:
σ List known people who are trustworthy
σ Rate people on a continuum of trustworthiness
σ Carry out behavioural experiments that involve trusting people
σ Keep a daily log of people who honour commitment

K’s sense of life, ‘Life is meaningless.’

Techniques:
List activities that formerly were rewarding
Schedule pleasurable/rewarding activities
Recognize that feelings of loss confirm meaning
Examine which goals or activities no longer seem meaningful and which now appear more important
Work toward an acceptance of death
Find meaning in each day

Group Supervision/Dynamics/Live Demo by Jess L

There was some confusion before the Live Demo of Redecision Therapy. Many turned up at East Coast Road after taking lunch as we were told only fruits would be served. To our surprise lunch was provided so some of us had double meals. Jessica seated us in a semi-circle and provided a bowl of candies as well as a box of tissues in the middle. She gave a brief introduction of her co-therapist after which she encouraged us to take part in the Live Demo as counselees.

A few of us volunteered ourselves after Jessica went over the TA Treatment Contract.

- Confidentiality
- No seagulling
- I am OK You are OK
- Mutual respect
- The right to pass
- No walking out
- Non violence

The two therapists then proceeded to demonstrate the four stages of intervention in Redecision Therapy.

1st Intervention:

Therapist invites client to ‘the scene’.

Therapist: “Go back to that ‘scene’.”

(The racket and repressed feelings were elicited.)

2nd Intervention:

If this continues for next 10 years, is this what you want to see happen? Is that what you want? (It’s possible to leave client with an impasse – as homework.)

3rd Intervention:

Amplify the script. Address the ‘CON’ contract. – ‘I came to see you because I heard you are a potent counselor.’ Tell client she/he must want to change for their own sake.

4th Intervention:

Therapist to provide PERMISSION, PROTECTION & show POTENCY. Redecision by client is made with A2. During the Adult debriefing, client is to come out with an Adult plan/resolution.

There was no apparent Script Cure after the Live Demo as it was rather brief. Perhaps mini-script cure was achieved. Or just social cure.

As therapist, I am to expect incremental progress in therapy as mini decisions over time will bring about changes in calibration and anchoring of new decisions.


Replace script
Educate
Deconfuse (adult ego decontaminate)
AwarE
Creative (2-Chair)
Intuitive
Spontaneous
Intimate
AutOnomous
Now

The Live Demo created an impact in my learning process. It has indeed displayed the dynamics of the therapy in all its subtleties. The flow of creativity, intuition and spontaneity was intensely present and a dire necessity to bring forth a desired decision.

I have fantasized being a potent Redecision therapist in the coming days. 

Spirituality & Addiction

Artwork (c)2006,www.psychotherapy.net

According to Rev Sam Kuna, Spirituality is a common characteristic of human race.
Webster’s Dictionary defines spirit as strong alcoholic liquor produced by distillation. This suggests the highly intoxicated ones are actually highly spiritual at the same time!! 

Webster also defines spirit as the Divine presence resident in humanity. Inside each of us is a Divine presence waiting to be awakened.

Addiction as a Primary Disease is not caused by anything else. And the addiction causes depression, anti-social behaviour, anxiety and psychotic symptoms.

Addiction as a Secondary Disease is a manifestation of a psychodynamic disturbance. It could be an attempt at self medicating depression, anxiety, personality problems or psychosis or a manifestation of a family pathology.

Proposed formulation: Addiction as both sinfulness and sickness. The word `sin’ was used to denote the act of hurting self (addict) and others (significant others). The disease can make spiritual growth more difficult – yet it makes the need for discipline and discipleship more evident. Treating the disease without treating sin is possible, but sin will manifest itself in another way. It is interesting that those who advocate the concept of addiction as an illness most vigorously advocate spirituality, reliance on God and spiritual growth with the same vigor! All the therapeutic communities in Singapore are faith-based half-way houses. 12 steps programmes have great success related to the spirituality/faith element. Existential approaches deal with emptiness and despair to break the extreme social and human isolation. Cognitive approaches speak about lifestyle change, and commend `religious beliefs’ as helpful to change.

The Spiritual Model of Recovery –

1. Filling the Existential Vacuum

The longing for pleasures of the moment or meaning of life can lead to crime, drugs, alcohol to fill the void.

2. Revitalizing Movements

This is an outpouring of energy, ideology and redirection to fill the void. This new identity offers hope, restores self-worth and meaning in life. History has shown that Religious and Spiritual experiences encourage well being and have proven to be therapeutic.

3. Three elements of Social Movement

a. Ideology

* Admission & confession of past mistakes
* Processing of guilt (it’s a poor motivator)
* Reframing the future based on the present
* Hope for future, freedom from addiction

b. Total Commitment

For any radical change, there must be a dedication to a new standard/pattern.

c. Enthusiasm

Breaks with former associates and befriends with others who become positive peers.
Life is transformed.

4. Finding a Worthwhile Mission

One finds life by losing it in the interests of others! A new sense of relief enables the individual to demonstrate love and concern for others.

The next day after I attended Sam Kuna’s talk, I met a client who has been battling with drug addiction. I have offered him my counseling support and hope I will remember my role as a spiritual counselor: To be patient and show respect for humanity. And to understand my own limitations as well.