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.

Sexual Addiction

Artwork (c)2006, www.psychotherapy.net


I was updated from the outset on some latest (and insightful) statistics on the sex industry: That it is the 3rd largest economic sector on the internet. There are more than 100,000 pornography Web sites and 200 new ones introduced daily! Most pornography is downloaded between 9 and 5 pm which makes this a corporate problem!

38% of sex addicts struggle with an eating disorder and 40% of sex addicts are women. 42% of sex addicts have a problem with chemical dependency. Many ‘sex addicts’ or ‘sex anorexics’ get treated under bi-polar disorder, or OCD. 17% of sex addicts have attempted suicide; 72% have thought of it.

Some new inputs I gathered during the symposium included the following:

- Addiction is chronic: The disease can be arrested, but not cured. Recovery requires both abstinence from the mood-altering substance and involvement in a lifelong process of growth and healing.

- Extreme Control of one’s life can be an addiction: Dieting, Sex Avoidance, Alcohol Avoidance, Saving, Hoarding, Risk Aversion, Compulsive Athleticism are some examples.

Within the addictive system, sexual experience becomes the reason for being – the primary relationship for the addict. The sexual experience is the source of nurturing, focus of energy, and the origin of excitement.. the remedy for pain and anxiety, the reward for success, and means for maintaining emotional balance.

The Addiction Cycle involves Preoccupation (Mental obsession), Ritualization (Triggers), Compulsive Sexual Behaviour and Despair (Guilt).

The Core Beliefs of a Sexual Addict (Carnes, 2001) is:

- I am basically a bad, unworthy person.
- No one would love me as I am.
- My needs are never going to be met if I have to depend upon others.
- Sex is my most important need.

There are 3 levels of sexual addiction:

Level 1 - Behaviours that are regarded as normal, acceptable or tolerable e.g. masturbation, pornography, prostitution
Level 2 - Behaviours which are clearly victimizing and for which legal sanctions are enforced e.g. voyeurism.

Level 3 – Behaviours which have grave consequences for the victims and legal consequences e.g. incest, rape.

(All levels of sexual addiction are painful.)

Cybersex – The triple engine (Cooper, 1998) - Accessibility, Affordability & Anonymity

Impaired thinking - ‘The Internet helps to broaden my sexual horizons.’ ‘Cybersex is just electrons; it’s not real.’

There are recreational users, at-risk users and sexual compulsive users.

Sexual Anorexia –

There is a tremendous fear of intimacy. Many sexual anorexics come from rigid homes, judgmental and non-affectionate parents.

Treatment –

In working the Steps and going through a treatment process addicts first tend to deny, then comply, then gain intellectual acceptance, and finally arrive at emotional acceptance.

The S-Anon Family Groups are a fellowship of the relatives and friends of sexually addicted people who share their experience, strength and hope in order to solve their common problems. The program of recovery is adapted from Alcoholics Anonymous and is based on the Twelve Steps and the Twelve Traditions.

Sexaholism is an addiction just like any other addiction – with the same elements of loss of control, tendency to continue the damaging behaviour despite negative consequences, and the need to do more of the behaviour to get the same result.

(Extracted from S-Anon Int’l Family Groups.)

Parenting in theDigital Age

Artwork (c)2006, www.psychotherapy.net


This workshop provided me with timely information and help as I am currently following up with a school refusal Sec 3 boy who is deeply addicted to computer games.

AP A Khoo is presently doing a research on computer addiction and her talk was entitled: The world of videogames – What’s so good and so bad about it. She talked about the different types of digital games - action and shooter games (e.g. tomb raider)/role-playing games (RPGs) (e.g. Everquest)/adventure games (e.g. Syberia)/real-time strategy (e.g. WarCraft)/simulators (e.g. Flight simulator)/sports (e.g. Tiger Woods Golf)/platform & puzzle games (e.g. Super Mario Bros).

Some benefits of game-playing:

1. develop strategic thinking & planning skills
2. generate creative solutions to problems
3. improve processing visual information and eye-hand coordination
4. provides esp males, with an outlet for pent-up emotions

Importance of digital games:

1. promote positive feelings
2. provide outlet for aggression, has cathartic effect
3. as learning tools
4. meet psychological needs
* entertainment and leisure
* emotional coping – fr loneliness, stress, low self-esteem (may increase self-esteem temporarily)
* escape from reality
* satisfying social needs, making new friends, strengthening friendships, generating sense of belonging and recognition
* need for challenge and achievement
* need for excitement
* need for power

Research shows positive effects:

* helping children with ADD
* use as a method of pain management
* improve laparoscopic skills
* process certain visual info as well as for combat
* games are part of well-adjusted lifestyle

Downside of exposure to violent games – increased acceptance of physical aggression. (short-term effects – aggressive thoughts; long-term effects – development of aggressive attitudes)

What parents can do:

Be aware of games that are available on the market and choose appropriate games for their children. (Use game ratings as a guide: ESRB – Entertainment Software Rating Board)

Have a deeper understanding of the nature (type and content) of games. (Set targets to be achieved in the game rather than limit the time they spend on the games.)

Supervise and monitor amount of time children/teenagers spend on games.

Play games with their children and advise them on appropriateness of emotions e.g. venting of anger.

Discuss issues such as gender and race stereotyping and the inappropriateness of violent solutions to real-life problems.

Encourage children and teenagers to have exciting and enjoyable offline real-life activities such as sports.

Research findings - Teenagers are LESS likely to meet someone face to face
when they have been given SPECIFIC-safety rules
* not allowed to arrange for face-to-face meetings
* not allowed to talk to strangers in chatrooms
* not allowed to give out personal information

when there is someone at home when they return from school

when there is close communication with parents at home

Games provide social interaction and friendships, empathy & help, achievement & challenge, leadership & teamwork.

The bottomline:

Is there a balance between online activities and that of the real world?

What activities are being compromised?

Redecision Therapy

Artwork (c)2006, www.psychotherapy.net


Jessica started off the session with BRAGGING ! She got the rest to brag and several of us responded in a childlike manner. (I supposed BRAGGING came from the FREE CHILD EGO.) I told Magdalene who was sitting next to me that I bragged all the time I had run out of things to brag. As I typed this journal, an urge came upon me to brag. I felt a great sense of admiration as I observed how my Chartered Scientist husband help a China company set up a rather well-equipped laboratory here in Singapore within 2 months, early this year. At age 60, he is steadfast and committed in his endeavors. And that’s impressive!

I was exposed to TA and Gelstalt during the Grad Dip and I did fairly well for my essay. With some basic understanding of TA and Gelstalt, my level of apprehension towards Redecision Therapy was manageable. In fact, I was looking forward to be equipped by the new tool. Jessica was a creative and intuitive facilitator in that she knew how much the students could chew per time. I was glad she went slowly with the more confusing aspect such as the different level of orders in Structural Analysis.

Going through the TA second time round reinforced my previous understanding of it. We were asked to partner with another to do our own Script Matrix. I was delighted to partner with Mag as I found her to be very intuitive too. The outcome of the process revealed our racket and repressed feelings as well as our early decisions. I cried a lot growing up (RACKET FEELING - SAD). It was my way of adapting to the harsh words thrown at me. Inside me I was scared, hurt and angry. (REPRESSED FEELINGS) My life position was I am not OK and you are not OK. And that explained my suicidal ideation. Mag helped free me from the injunctions by giving me the permission to Speak Up, to be Assertive and to be Real.

I learnt what it meant to confront the “CON” or ways in which the client discount the self, the therapist or the reality of the situation. (For e.g., help my son to realize he is in the wrong.) When client contracts to change but 2 parts of his personality are pushing in opposite directions with equal force, he is said to be `stuck’ with a problem (Impasse). Impasse clarification helps prepare the client for Redecision work. The 1st , 2nd and 3rd degree Impasses were not difficult to understand. However, the Redecision Work can be a challenge. Clients may find it awkward to go back to the early scene to re-connect with and settle unfinished business with their late parents especially if the clients had been taught to respect the elders at all times.

Redecision Therapy will be adopted in my counseling work when my clients are willing to track back to an early trauma to re-experience it and change the early decision.

Multicultural Counselling and Therapy (MCT): A Model of Integrating

Artwork (c)2006, www.psychotherapy.net

MCT is the fourth-force in counseling, after Psychodynamic Psychotherapy (1st), Behaviorism Therapy (2nd) and Humanistic Approach (3rd). Benny talked about the ‘FIT’ between Client and Therapist in the area of congruency, sensitivity and therapeutic alignment. MCT brings together two elements: The Person of the therapist and the Cultural context of therapy. Culture influences individuals and the therapeutic process.

I like this definition of culture (Castillo ’97 p 20) - A culture is the sum total of knowledge passed from generation to generation within any given society. This body of language includes language, forms of art and expression, religion, social and political structure, economic systems and legal systems, norms of behavior, ideas about illness and healing, and so on.

We were asked to name 5 personal descriptors each. I noticed that all of us except for a couple of negative ones gave complete positive descriptions of ourselves. I wonder if it was culturally expected of us Counselors to present ourselves positively.

My main clientele are similar to me in that they are parents and unemployed but dissimilar in more aspects, such as they are either separated/divorced or single parents. They are also from a low income family therefore not highly educated, and may have been convicted previously. They may also embrace a different religion. For a start, I will have to ensure the counseling venue has to be a neutral place (that is, not a church setting if they are Muslims). I will also have to figure out if they are able to pay for the use of counseling clinic.

The goal of MCT is to be intentionally cultural. 3 areas of competencies of culturally intentional counselors are:

The ability to create options to clients, implementing process of therapy that is congruent to the clients as well as the ability to formulate plans, act on many possibilities existing in a culture and reflect on these actions.

MCT is more of a meta-therapeutic approach. I have to identify frameworks and concrete helping skills and strategies that are culturally sensitive. MCT is best described as a method than a theory. It begins with an awareness of self and the pervasiveness of culture throughout the therapeutic process. It is practiced with a set of guidelines rather than applied with techniques.

Constructive Psychotherapy

Artwork (c)2006, www.psychotherapy.net

Constructive Psychotherapeutic framework was adopted in my counseling work with Barbara (Case history in Appendix A). Constructivism is essentially a range of perspectives on human experiencing. `To construct’ is to create order as order is essential to perception and fundamental to meaning. (Mahoney, 2003) The implicit goal of psychotherapy is to help disordered individual return to order. It addresses both the PRACTICAL (i.e., what can one do to help) and the PERSONAL side of psychotherapy (i.e., what it feels like to change).

Constructive assessment and intervention are interwoven into the fabric of a developing human relationship. Each meeting with Barbara allowed me and her to examine and creatively experiment with our experience of each other. There are three interwoven Levels of Focus in Constructive Psychotherapy. They are: PROBLEMS, PATTERNS AND PROCESSES.

PROBLEMs & THEMEs of Constructivism

At this level of focus, problem is defined as a felt discrepancy between the way things are and the way they are expected to be. (Mahoney, 2003) Barbara was brought into therapy because she could barely cope with her problems. As a constructive psychotherapist in face of the complexities of human change, I asked myself what I could do to help her regain the courage and hope she needs to face the days ahead.

Constructive Theme/Assessment - ACTIVITY

In constructivism, the individual is deemed an active agent in the process of experiencing. We are each engaged in acts of selection at every moment (Bateson, 2000). Daily, Barbara is actively participating in shaping her own experiences by making choices that influence who she is. As Barbara tends to anticipate what she remembers, she expects her future to resemble her past. And this is making her downcast and miserable each day.

During our interaction I noticed she was trembling a little and I attended to it by telling her my observation. She revealed that her body often shook whenever she recalled her past. In this instance, how her parents went round borrowing money from relatives on the pretext of settling her school fees. She resented them for using her to solicit money. She wished she had not been born and could stop worrying about her future.

Constructive Theme/Assessment – ORDER

From the outset, I had to view Barbara as a constructivist herself, i.e. she has the capacity to construct meanings in her life. (Mahoney, 2003) At age 18 Barbara found her life unsettling and too challenging. She could not understand or accept all the bad things happening to and around her. Her world used to be chaotic and life-threatening especially when the `loan-sharks’ came banging on the door late in the night and she was left with the maid to fend for themselves. I sensed anguish and disgust when she revisited the past. She wished she could rid herself of such negative emotions, yet there is a powerful momentum to the ways she has come to feel. Knowing her parents’ low tolerance for the slightest rebuttal from her, Barbara has learnt to suppress her displeasure. She harbored silent protests and shed quiet tears.

Constructive Theme/Assessment – SELF

Piaget (1987) developed a model of cognitive development in which he described knowing as a quest for a dynamic balance between what is familiar and what is novel. He noted that we organize our worlds by organizing ourselves. And self is a process; a fluid coherence of (unique) perspective from which we experience and this sense of self emerges and changes in relationship to others.

To help Barbara optimally, I must know how she experiences herself – how she relates to herself, how she views her past and what seems possible and impossible for her future. After knowing her strengths and weaknesses, I will find out what she sees as options. Barbara felt like a passive pawn in the game of life because no one in the family took her seriously. She did not think she was capable of making sound decisions on her own. Barbara saw herself negatively with not much agency/freedom. She seemed to have limited resources and personal capacity. She harbored irrational/unrealistic idea of her not being able to do anything to change the way things were.

Constructive Theme/Assessment - RELATIONSHIPS

Active organization of self takes place `with’ and `through’ social bonds & systems of symbols. (Harding, Keller, Knorr-Cetina). The quest for order and meaning is often expressed in narrative form.

As Barbara’s story unfolded during the session, I sensed her struggles to break herself free from the past. Living primarily in the present is often a challenge when she is constantly reminded of the poverty state she was in and is still in. Barbara could not understand why her parents did not love and care for her enough to provide for all her needs. She particularly missed her deceased grandmother whom she believed would do all she could to bail her out of her misery. I noted an aura of ease and comfort on her face when she talked about her grandmother. More importantly, Barbara needed to be encouraged to develop the balanced skill of being in the present as well as planning ahead.

Constructive Theme/Assessment - DEVELOPMENT

The disorder experienced by Barbara is a natural expression of life trying to reorganize itself. The developmental process is often a zigzag course. As the human change processes can be complex, I need to be creative, affirming and respectful of Barbara’s capacities for development. I must meet her on her own grounds. I need to find out whom she confides in and how she has been hurt and helped in her cycles and spirals of experiencing. (Mahoney, 2003)

PATTERNs (Core Ordering Principles)

The presenting problem may have been the proverbial straw that made Barbara’s life burden too much. I acknowledged her agreeing to receive help as healthy and self-caring response to feeling overwhelmed. Barbara asked, `Why do I always find myself feeling frustrated, resentful and insecure? What have I done to deserve all these?’ Barbara’s adaptation to her worlds has required that she develops structures that allow her to anticipate and respond in systematic ways. She finds herself stuck in a pattern of experiencing; it seemed useful to trace the pattern backward in time. (Mahoney, 2003)

Mahoney explained that the developmental essence of constructivism is the reason why the constructive psychotherapy embraces a balance between past experiences and present action. Life-Review Exercises was undertaken to give meaning to present pattern of experiencing in Barbara’s life and to create new possibilities for future experiencing. The Personal Experience Report (Appendix D – sample) provides many questions aimed at evoking capsule summaries of Barbara’s early experiences.

There are 4 themes (Reality, Self, Value and Power) in the tacit dimension (Michael Polanyi, 1966) of Core Ordering Processes. These are deeply abstract processes. They are not easy to change.

Where was Barbara’s reality grounded? She had developed a distorted cognition that she deserved the unfair treatment her family members imposed on her. Her self-belief was a negative one as she blamed herself for bringing the bad luck to the family. She did not have a sense of agency/control in her life because her parents would make sure she report to them regularly. What kind of value guides her emotional judgment? She considered it bad to go against them despite being exploited.

It was here I explored where she wanted to invest her current energy. I had to ensure foreclosure do not take place to avoid a felt sense of isolation or unworthiness. I allowed ample time and space for her to bottom out of the negative experiencing.
By doing so, Barbara worked at pattern levels while trying to solve the school fee problem. She was led to examine the bigger picture or the underlying issues. When changes take place, what changes in significant and enduring ways will be her core processes of experiencing herself and her world.

PROCESSes - Basic Principles of Constructive Practice

I embarked on process work on the inner (intra-personal) level of Barbara. According to Mahoney, constructivism is focused on possibilities, strengths, personal resources, and human resilience. (Mahoney, 2003)

Relationship

In Constructive Psychotherapy there is an attempt to engage client in a consensually authentic process of human presence. (Martin, 1958) In view of the cycles of experiencing, I need to modulate my provision of comfort and challenge according to Barbara’s changing needs. The therapeutic relationship is one of respectful collaboration, trust, safety, and activity. Barbara who is the primary agent of change (as opposed to object of change) is to be told of the nonlinear, tacit and continuing aspects of her development. The meaning making achieved through this joint responsibility helps Barbara make sense of the past and promote a more hopeful vision of the future.
Rationale

My primary responsibilities as a therapist are to honor the felt experience of Barbara. I am to offer compassion, hope and trust, also practical suggestions for coping and incorporate techniques that have been tried and tested. As Barbara’s old ways of being fail to satisfy the demands of new challenges in life, she will need to try something different, explore alternatives, and turn challenges into opportunities.

Barbara’s primary responsibilities are to remain as engaged as possible in her own development. Her patience and persistence will help her regain a sense of order in life.

Rituals

Barbara needs to be equipped with problem-solving skills so as to increase her capacities to generate ideas for potential solutions to specific problems in life. Barbara needs to learn therapeutic techniques that involve creative reconstructions of her life stories (narratives). Engaging her in therapeutic writing such as Unsent Letter or Personal Journaling may help to modify the meaning(s) of her past and changes her sense of agency, alternative possibilities and hope. Her careful self-observation of the experience and effects of a ritual can help to strengthen her new patterns of adjustment.

Barbara also expressed her intention to change to a more self-comforting and self-caring person by actively pursuing some structured experiments in experiencing such as Self-Comforting Exercise (Appendix B).

Conclusion

The Constructive Psychotherapy framework basically provided me with the structure to work on Barbara with her problems. It is expected of Barbara to experience changes in baby steps (gradual) or large leap (abrupt). (Thelen, 1992). I must not expect Barbara to embrace changes with open arms as she needs to protect herself against changing too much, too quickly. I need to anticipate cycles of opening and closing in her developmental experiences as she seeks to achieve a balance. (Mahoney, 2003)

The problem-solving process Barbara and I went through enabled her to generate a list of options for help to solve her presenting problem. We experimented with many options and were surprised when one of the options yielded a positive outcome. Barbara’s outstanding school fees have since been fully paid for. Although Barbara is still worried about her future, especially how her Polytechnic education will be funded, she seemed more resilient than when I first met her. During the later sessions, Barbara displayed greater openness to experience. With increased capacities to self-comfort, she experienced greater sense of empowerment. I observed a more hopeful Barbara with improved self-esteem and increased self-awareness.


Appendix A

Case history of Barbara (not her real name)

Bio-data of Barbara:

Barbara, 18, was a foreign student in a local school here. She is the youngest of three in her family. She has just graduated from XXX secondary school after having sat for her N and O levels examinations. She will be embarking on a nursing course in a local polytechnic here.

Barbara was referred to me by her secondary school’s Vice-Principal, Mrs Koong.

Barbara’s Family (non-Singaporeans):
3-Generational Genogram of Barbara

Father and Mother:

They were highly successful business partners in the early years of their marriage. As they were busy building their business empire, their children were left in the care of their paternal grandmother and maids. Soon after Barbara was born, their business relationship with their suppliers turned sour. The couple suffered mental and financial setback when they chose to take their suppliers to court. Soon they ran into huge debts, chalking up on legal costs and had to surrender their home to the banks. The loan sharks were after them and they had to go into hiding.

Barbara’s parents are now living and working in City A of Country M. From time to time they would talk about their past glorious days when the family gets together. Without fail they would point their fingers at Barbara and blame her for bringing bad luck to the family. Today, Barbara seemed to believe she has been the jinx in her family.

Older Siblings:

After the grandmother’s health dived due to poor diet and distress, she soon passed away. The grand-children were left behind with the maid to fend for themselves when the parents went into hiding. For days they would feed themselves on Maggie mee until the parents came by to drop off more palatable & wholesome food. Barbara and her siblings commuted to Singapore school from the tender age of 7. They had to wake up at 4 am and would not be home till 7 pm or later if there was congestion on the causeway. Both her siblings’ education was disrupted after O levels due to the financial difficulty faced by the family. They are now staying and working in City B of Country M. Barbara stays with them whenever she is back there but Barbara does not share her problems with them.

Presenting problem:

Barbara was in tears when Mrs Koong the Vice Principal told her her O level result slip could not be released to her as her school fees for the last two years have not been paid for. Barbara’s mother promised to settle the arrears in January but she did not show up. Neither was she contactable, according to Mrs Koong. Barbara was devastated because she needed to submit the result slip to the Polytechnic in a couple of weeks’ time. Barbara was a picture of gloom when I met up with her. She looked pale and way too thin for her height. Her mouth drooped at the sides and her gaze was either on the floor or on the wall.

Appendix B

Part 1: Background and current concerns

Name: Barbara Age: 18

Occupation: Student

With whom do you now live? Siblings & Maid

Describe the primary problem or life concern that you would like help with.

I need to find the money to pay for the outstanding school fees or else
I will not be able to enroll myself for a Poly education.

I can’t stand my parents. They use me and don’t care about me.

In a few words, how would you describe yourself as a person?

I think I give in too much to my parents.

What are you now doing to cope with or resolve the problem?

I fret and fret but end up being scolded by my mother.

Have you tried any other solutions in the past?

My parents should provide the solutions.

Do you face any immediate challenges that we should deal with as soon as possible?

My parents don’t give me any pocket money. I go without food some days.

I am now feeling or I have recently been feeling…. Despair & hopeless

I have been having experiences of sleeplessness

What are your sources of strength? My VP in Sec school cares for me.

How do you cope when under stress? I called my VP and share with her my problems.

How can I help you? I need to know how to solve the money problem.

Part 2: Emotional Life

Over the course of the last 90 days, to what extent have you experienced each of the following?

Anger & other negative feelings

Never 0 1 2 3 4 Often

When you were a child, which feelings or emotions were you taught to think of as 'good’ or 'bad’?

'good’: If I obeyed my parents
'bad’: If I disobeyed my parents


Which of the following expressions of emotions were discouraged when you were a child? (circle all that apply)

Crying whining laughing pouting arguing

How would you describe your childhood in general?
(circle one)

Very unhappy 1 2 3 4 5 6 7 8 9 10 Very happy

Each of the following statements describes experiences you may have had as a child. Cross all that apply to you and your childhood.

_____ Our family life was happy. ___X__ I enjoyed school.

____ I felt loved and respected.

For the following, underline which words would make the statement true.

_X___ My mother/father was often or entirely absent.

My mother…. _X__ was sometimes violent.

My father….. ___ was abused or abandoned as a child.


In their order of appearance in your life (from first to last), who were the people by whom you felt loved?


Name Relation to you

1. XXX My paternal grandmother

What was your happiest experience as a child?

My paternal grandmother gave me pocket money everyday.

What was your most emotionally painful experience as a child?

When my paternal grandmother passed away.

Part 3: Spirituality

What were your parent’s religions? How important was religion to them?

They prayed to all kinds of gods. Now they are Christians. But I am not sure how important is religion to them.

What is your current religion or spiritual orientation?
Christianity.

Part 4: Recreation

What are your favourite things to do for fun?

SMS-ing.

Are you now involved in any form of regular physical exercise or stretching?

No. No mood.

Appendix E

Self-Comforting Exercise

Purpose: To explore and develop Barbara’s capacities to ask for and receive comfort from herself.

Duration: 20 minutes with no distraction.

Instruction to Barbara:

Assume a comfortable position, and be as relaxed as possible.
Imagine one part of you wants to be held or comforted for reassurance, forgiveness, strength or understanding.
Imagine another part of you that is deeply caring, compassionate, and generous – the part of you that is called upon when your friends need your help.
Pretend that you can give a different voice to these two parts.
Begin with the voice of the part of you that is asking for comfort. Say things like, `I feel neglected.’ Then pause.
Allow the comforting part of you to respond soothingly and reassuringly.
Say things like, `Yes, dear, I know you feel neglected. I am here with
you.’ Pause again and allow the hurting side to respond.

Allow a conversation to emerge between the two parts. It may feel appropriate for you to stroke the area of your body that is tense and hurting. This will ease up at the end of session.

When Barbara feels ready to finish the exercise, she invites each part of her to say something to the other that expresses affection and appreciation.

References

Mahoney, M. J. (2003). Constructive Psychotherapy: A practical guide. New York:
Guilford.

Bateson, P., & Martin, P. (2000). Design for a life. New York: Touchstone.

Piaget, J. (1987). Possibility and necessity: Vol.1. The role of possibility in cognitive development (H.Feider, Trans.). Minneapolis: University of Minnesota Press.

Harding, D.E. (1961). On having no head: Zen and the rediscovery of the obvious.
London: Penguin.

Keller, E. F. (1985). Reflections on gender and science. New Haven, CT: Yale
University Press.

Knorr-Cetina, K. (1999) Epistemic cultures: How the sciences make knowledge.
Cambridge, MA: Harvard University Press

Polanyi, M. (1966). The tacit dimension. New York: Doubleday.

Buber, M. (1958). I and thou. New York: Scribner’s.

Thelen, E. (1992). Development as a dynamic system. Current Directions in Psychological Science, 1, 189-193