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)