masking

My female owner hitched a ride to school from someone today. Over the past months of training, my female owner has learnt not to let go of slight hesitation of responses or responses that seem to be masking the true feelings. In other words, people tend to say what is socially expected at the first instance but when you read into the non-verbals, you can pick out incongruent messages and with gentle probing, can help the person to express these inner feelings and thoughts.

My female owner did just that today in the car. She waited for him to go beyond the surface and was glad she didn’t accept his socially expected answer, coz allowing him space to express himself led to a fruitful conversation. My female owner started asking him questions that she would ask any of her clients and found it fascinating how her friend answered her spontaneously.

She wondered if he even knew that she was doing some form of therapy on him. My female owner mused that if she tried any of those questions (“how would you know if…”, “what did you do that was helpful?” etc) on her psych/counselling/social work friends, they would have retorted almost immediately with, “stop using your psych-speak on me?” So hard to support helping professionals.

mse

My female owner had another fulfilling day at placement yesterday. The Singaporean working ethics was unleashed in her, as she worked tirelessly from 0800 to 1830hr. Her official hours are 0830 to 1730hr. She was so busy, she didn’t even have time to read her work emails and lunch was just a 15min refill, just to keep her stomach from growling. Engaging in meaningful work kept her adrenalin going and she would have gone on, if not for the fact that she had a dinner appointment to rush to.

She also had her first supervision session where her supervisor and her went over a needle-phobia case. Although my female owner had heard mixed things about her supervisor (which made her a little apprehensive), my female owner said that it was one of the most educational sessions she ever had with any supervisor. Even running through MSE (or mental state examination) – something that is often overlooked by clinicians – was a novel experience. No one ever taught her the nuances/ art of doing an MSE, not even during her coursework.

Sounds like she is enjoying herself pretty much.

sand play

Ever heard of sand play therapy?

Apparently, it is a non-intrusive form of play therapy that allows children (or adults) to play out what is happening in their world. The therapist provides a sand tray, water, miniature objects and materials so that the child can imaginatively create scenes in the circumscribed space of the sand tray. The scene of picture that is constructed is a reflection of the child's inner and outer worlds and an expression of both conscious and unconscious thoughts.

One of the school counsellors at my female owner's placement specialises in sand tray. Her clients are mostly primary school children. Ever open to new ideas, my female owner decided to take up her offer to have a sand play session.

It turned out to be psychodynamic in practice. My female owner chose certain items from the shelf and arranged them in the sand tray (see her creation below). The counsellor then guided her to tell the story behind each placement. My female owner could see for herself how her story was an extension of her personality, inner thoughts and current concerns.

My female owner told her story before the counselor revealed what each region of the sand tray meant. The centre: Self. Left bottom: Sub-conscious. Left top: Religion or spirituality. Right top: Relationship with earthly father/ future. Right: Relationship with earthly mother. Right bottom: Relationships.

Eerie but true… my female owner’s story tallied with the various domains. Specifically, she pointed out the tiger as being her mother and the group of turtles as a group of friends. Notice that little orange turtle which is buried in the sand too? That placement is hard to relate to any domain I suppose. She saw herself as being on the boat, about to go out to explore things… and the top right, she expressed distressed that it was empty, glaringly empty. The sub-conscious domain was hard to explain. My female owner said that she didn’t know why she put leaves and pebbles there, but she pictured nature as she placed things there. When asked fast nature (e.g. wind) or still, she said, it was still. Hmm… Perhaps she is at peace at this period of time. The spiritual side, represented by the relaxed dog. Wahaha. Lazy Christian? The counselor didn’t draw any reference to religion but suggested that spiritually, she is calm and relaxed.

The thing about psychodynamic is that any interpretation can be correct, and you are often trying to find explanations that fit what your story is. Nonetheless, my female owner was astonished at the accurate tally of her story and most of the domains.

soup

The sudden death of Singapore’s Father of Counselling sparked off a conversation between my female owner and Counselling Fren.

My female owner always had high regards for Counselling Fren’s counselling skills. And she found out that he had actually received clinical supervision from the Father of Counselling. Now, that explains something, doesn’t it?

So my female owner asked Counselling Fren what the main lessons he learnt from him were. Without hesitation, he listed the following:

· just be urself
· u are the most effective tool in any therapeutic r/s
· doing nothing is actually doing smthg
· always ask the reasons behind every actions

Ah, chicken soup for the counsellor?

sense

My female owner is currently trying to make sense of her externship experience. As you may already know, she has been feeling shortchanged about her current placement. Having to start up a psychological service in an unfamiliar, never tried before population group (residential aged care) is not what a postgrad psychologist-in-training would expect to undertake during her training. In all other placements, the psychological service is, expectedly, up and running. All the trainee needs to do is to go in, see clients, meet with her supervisor, clock the hours and get out. Here, my female owner is really left alone, with a supervisor who has minimal experience in the current setting. Talk about being left alone. She spends a good part of her time just chit-chatting with the older adults. Once in a while, she throws in a therapeutic question but the older adults tend to go all over the place and my female owner has no choice but to flow with them.

Admittedly, she is struggling to understand how God can make something good out of this situation. She finds no pleasure in this externship, whatever good feelings she has centre around being relieved that “at least I did some form of clinical work today”. She gets gloomy on Tuesday nights because she goes for work on Wednesdays and Thursdays and becomes really liberated on Thursday evenings. Truth be told, she can’t wait for this to be over. 10 more weeks she says.

Alas, the reflective side of her screams out “enjoy the process!” There is something surreal about working with people who are in their 80+ and 90+. Looking at their life experiences, aging process and human spirit, it is not hard to wonder how your own life would turn out in decades to come. Old people are not a homogenous lot. They are individuals, with different needs, personalities and abilities. Like many younger people, some are happy and contented, some are disatisfied about life. The demented (a common phenomena among the aged), though having some memory loss and disorientation to their current reality, is still capable of feeling depressed, unwanted and insecure. They simply live in an altered state of reality.

Some comments that she has heard so far:

“Thank you for taking an interest.” – 88 year-old man with mild dementia.

“Why is dying so hard?” – 96 year-old frail woman who used to be able to walk on her hands, now afflicted with multiple illnesses. Is living till such an old age a curse? Or a blessing?

“I try to be happy” – 87 year-old verbally aggressive woman who, in a tender moment, shows her vulnerable side. The desperation of a highly depressed woman.

“Can she play cards?” – 67 year-old man who was looking for a third person to join the cards table. My female owner ended up playing jim rummy with them. (At the same time, a vision of her playing bridge and taidi with her aged friends in an old folks’ home flashed by her).

wish

My female owner had a better day. She dragged herself to school in the hot autumn sun to complete some miscellaneous bits of work and to borrow some books to start her assignment on “workplace bullying”. No prizes for guessing why she chose to write on that topic, in a module entitled “Counselling and violence”. My female owner is now two shades darker, no thanks to the roasting properties of the Brisbane sun.

Her Singaporean friend contacted her about something upsetting. At such times, my female owner wishes that she knows the right words to say to encourage or comfort people. She finds it so hard to compose her thoughts and communicate them through SMS. I think I know what she means, you can’t really ask someone to “tell me more” in SMS and hope to get a proper understanding of the situation. What can you type in 160 characters that would make a difference to someone who is upset?

At night, she returned home and from the window, she saw her housemates sitting at the dining table talking solemnly. Female Housemate actually went back to her room by the time my female owner opened the front door. Male Housemate was left sitting at the table. He looked distressed and opened up to her about his stress. In a horrible mix of English and Mandarin, my female owner tried to understand what he was going through and provided some basic counselling. Again, my female owner was left wondering if she could have done any better to help a distressed person.

As a counsellor, who she is, is her main tool in effecting change. My female owner realises that it is time to sharpen herself so that she can be more effective in helping others.

Do Try

Demonstrating the difference between “trying” and “doing”

Please try to pick up the pen lying on the table there next to you.

(Most clients will pick it up).

No, I didn’t say to pick up the pen. I said to try to pick up the pen. Please, again, try to pick up the pen.

(At this point, clients typically either pick up the pen again or move their hand close to it, hovering over it, as if their hand were paralysed.)

No, I didn’t say move your hand toward the pen and then stop. I said try to pick up the pen. Can you do it, or is it simply the case that you either choose to pick up the pen or choose not to? What if trying to ask our boss for that raise we’ve talked about is like trying to pick up the pen?


No! Try not. Do. Or do not. There is no try. [Yoda]

counseling

My female owner had a mini-counselling session with her trained counselor friend last night. After a while of talking/ typing (since it’s MSN), the friend commented that her counseling skills had improved.

Wahaha. Always one for feedback, my female owner asked in what ways and the friend highlighted that her questions provoked more thinking whereas in the past, she was more directive.

Yay! An endorsement from a trained personnel. My female owner is heading in the right direction.

The power of asking the right questions.

Actually, my female owner had never been trained in counseling. She didn’t pursue that module in school and learnt her hand-me-down skills from her ex-colleagues at work, some of whom hated to do counseling! And using those hand-me-down skills (thankfully she was armed with a short stint at a mental hospital), she had to assess lay people on their aptitude to be a para-counselor, conduct workshops to train them in counseling and provide counseling to others who need it.

Going to Brisbane, she starts to learn the science behind the art and is now able to apply the techniques with greater appreciation.

therapeutic

Having completed about 85hrs of direct client contact (my female owner needs 115hrs more to pass her internship), my female owner has reached a stage where she wants to undergo psychotherapy herself. The experience, she reckons, would be helpful in understanding what her clients go through as they come to see her week after week. In addition, she expects it to be therapeutic, addressing some of the misses in her life.

Any recommendations anyone?

perplexed

Remember the male client who terminated on my female owner a few months ago?

There’s part 2 to the story.

His 80-year-old mother called the clinic last Friday on his instructions. He wanted his mother to inform my female owner that he was currently in hospital and that he was sorry for not contacting her earlier.

My female owner was perplexed at his actions coz he was the one who terminated on her. She called her client (or ex-client?) on Monday and learnt that he was still in hospital. Hence, she was not able to get more information.

Her clinical supervisors (now she has two) speculated that

It could be a courtesy call.
His way of testing waters/ cry for help.
A personality disorder at work (that also explained the reason for the abrupt termination).

termination

My female owner’s anxious client terminated on her today. He called up the clinic to leave a message for her.

I suppose it’s hard not to take it personal whenever a client terminates on you. It didn’t help that the clinic secretary gave her a stern look as she passed the message to her.

Was it something you said or did during the session? Or was it something you should have said or done which you didn’t? Or was it some client factor like motivation or some extenuating factor like lack of finances?

My female tried to remind herself not to take it personal, coz there could be a whole host of reasons for client termination. However, it would still be important to do some self-reflection to see what she can learn from this experience. I know that there are a lot of things she would have done differently if she had the chance to redo the two sessions she had with him.

As a matter of practice, she called the client (crossing her fingers that he would be willing to talk to her) to check on him. His reason was “I’m feeling much better” already. In his usual sweeping style, he said that he was “taking control of his destiny” and taking steps to get a job.

Then it dawned upon her that there was a similar instance in the past when he tried hypnotherapy once and he discontinued after 2 sessions (out of 4), because he “felt better”. A way of rationalising to help herself feel better?

questions

After practicing as an intern psychologist for a few weeks, my female owner mused that her clients pay her to ask questions that they have to answer themselves.

If there’s one thing which my female owner can wish for, it is the ability to ask the right questions. Questions that would help to clarify matters, questions that would create positive ambivalence in the receiver, questions that would bring the subconscious into awareness. Asking the right questions can help to zoom into the main issues and help the receiver to confront issues that he had been avoiding.

My female owner is not one to ask (many) questions. Growing up in an Asian culture, she has been well trained not to ask questions and to accept things as they are. Keeping questions to herself meant that she would somehow rationalise the answers by making naïve assumptions.

Feedback from her clinical supervisor constantly revolved around one issue – being able to get specific details on the client’s presenting problems. Again and again, my female owner was unable to grasp the full understanding of the problem because she didn’t ask the right questions or didn’t ask enough of the right questions.

The art of asking questions. A gift that my female owner urgently needs.

round face

People say that babies like round things and that people with round faces look more friendly. My female owner attests to that. She has noticed that babies take to her readily, even though she ignores them. For example:

• Baby was at a table 2m away from female owner at a coffeeshop in Singapore. Baby kept looking at her. Female owner had no choice but to smile back and make faces at Baby. Baby kept looking and started to smile and laugh. Baby got so amused and kept laughing. He didn’t want to eat….and got scolded by mother.
• Female owner was in the bus. Baby was sitting diagonally across from her, 1.5m away. Baby kept looking. Female owner had to do as above. Baby started to smile…and female owner missed her bus stop.

I’ve said this a few times, that my female owner feels like a fish out of water, working at the parenting and family clinic, as she has minimal experience with children and parents. She’s really more into animals. But that’s precisely why she chose to be there anyway. She wanted to try out new things (she gets a kick making things difficult for herself).

This week, she had her parent-clients bring in their children for observations. In total, she saw a 3-yr-old child with autism, a sibling pair (brother, 7; sister, 5), and a pre-teen girl (9-yr-old).

The mother of the pre-teen girl was highly anxious about leaving the girl alone with my female owner, coz she felt that her daughter was not going to say anything more than “good, thanks”. That was exactly what happened, when my female owner spoke to her daughter in the presence of her parents and the mother gave my female owner a knowing look. Then, the parents left the room to allow some individual time. Using the tips she read from a book on how to interview children, she started her very first child interview. Some tips include

• Start with the positives – ask about school and what the child likes about it.
• Praise the child constantly for sharing – “that’s very nice of you to tell me that”. The power of praise cannot be emphasised more. It works really well with children (and adults of course). Just remember that you need to be specific about what the child did well.
• Express interest in what the child is sharing – “that’s really interesting”
• Check if the child is comfortable sharing potentially sensitive things – “is it okay if I ask about….?”
• Thank the child if she agrees – “thank you so much for allowing me to….”
• Mirror the child’s body language – this girl was apparently spilling her arms over the arms of the sofa, so my female owner went down to her level and she noticed the girl relaxing even more
• Maintain eye contact

The little girl ended up talking so much that her father knocked on the door to check if things were ok. After the session, she drew some pictures for my female owner to see. The mother must have been quite impressed (esp when she found out that the girl asked her father whether she would be seeing my female owner again) coz she joked about having my female owner over as a baby-sitter.

It must have been the round face. See? Putting on weight is good after all. Now my female owner has a rounder than round face which makes it even easier for her to connect to children.

peek

My female owner has her own version of weekly therapy sessions. She meets with her clinical supervisor at 1400hr every Wed (yes, right in the middle of the week!) to discuss her cases and get clinical guidance. The supervisor plays many roles - therapist, teacher, mentor, role model, critique. And after each session, my female owner writes up a supervision record, detailing what was discussed (parallels her client session notes).

I managed to get a peek into the latest one (today's). It's pretty boring.. unless you are a parent.. Here's a portion of what she wrote (hope she doesn't use what she learns on us):

Intake interviews

• It is very important to get specific examples of problem behaviours. This includes what happened before, during and after the event: sequence of behaviour, what did the parents do/ respond? Is this a typical occurrence, how often does it happen, how long does it last etc?
• Check for level of severity: e.g. no of times/ day. For compliance, ask “out of 10 instructions, how many will she obey?” Need to ascertain baseline/ percentage. Also, note whether instructions tend to be repeated.
• From the information gathered, we will know more about parenting styles, perpetuating factors (e.g. accidental rewards through screaming, being yelled at by parents as a form of getting attention, modelling parents’ behaviours), precipitating factors etc. Only then can we do an accurate formulation. We cannot base our formulation on speculation.
• When giving feedback/ discussing about problem behaviours, use behavioural descriptors such as “yell”, “scream” and not labels like “temper tantrums”, “emotional outburst”, “rude”. Make sure that you state things as they are. Be objective.
• Do a reality-check on parents’ perceptions. Sometimes they may exaggerate, sometimes they under-estimate. Never take anything at face-value. Use the information given to identify the underlying mechanisms that perpetuates the problem behaviours (e.g. inconsistent discipline resulting in accidental rewards? Escalation traps?).
• When parents use labels, clarify: e.g. “what does being ‘rude’ look like?” What was said? How was it said (tone/ volume of voice)? What happened after that?
• Get parents to talk through how they use rewards and punishments with the child. The strategies have been shown to work. If they don’t, it usually means that something has not been done correctly. So need to identify those areas with the parents.

School observations

• Need to be done before seeing the child in the clinic
• Consider what information you need and whether you can obtain it from other means (e.g. parents or teachers – usually a very good and reliable source of information).
• Sometimes you may not get to observe what you intend to observe (e.g. interaction with peers)

Parent-child observations

• Main consideration: setting up a social interaction that is able to answer the questions that you want.
• Younger children: play and clean up. Check for things like no of instructions given, no of instructions repeated, praise, delay in responding to misbehaviour
• Older children: problem solving/ discussion. Get parents to come up with a list of problems to discuss while you interview the child to get his perspective on things. At the end of the time with the child, help him to generate 2-3 problems that he would like to discuss with his parents. Put the family together in the room and observe them from the point where they decide what to discuss (one from child and one from parents). Max 15mins of observation.
• Use the questionnaires to decide what you want to focus/ keep track on.

Interviewing children

• For children less than 7, the process of interviewing is more important than the content of what they say (because they may not be able to articulate their responses in a manner that you will want them to). They may provide trivial answers to your question (e.g. if you have a magic wand and can change anything about your family, what would it be?).
• For younger children, you may be able to get the answers you want from their care-givers. So you may not need to interview them. Interviews will be about 10mins. For older children, it would be about 20mins.
• Observe the way they interact with you: eye contact, posture, ability to follow instructions etc. Especially if you are looking out for symptoms of autism or ADHD.
• Can get the child to draw his family: observe the way he holds the pen, how he starts on the drawing.
• Externalising children would not see their behaviours as a problem, because they get what they want. Their parents would see their behaviours as problematic.
• Internalising children may have more insight, as they do not get what they want. Hence, their answers may provide more information to what they are feeling.

Sharing of assessment findings

• Use information from: Intake interview with the parents, interview with the child, questionnaires, parent-child observations, school reports, information/ reports from other mental health professionals.
• Look out for consistencies in data (e.g. laxness vis-à-vis intake interview) and discrepancies.

Report writing

• Need to be comprehensive in the report by including the background of the child’s problem behaviour. Otherwise, it may create confusion when other people try to interpret the report later on. Numbers, without any context, don’t mean anything.

Case formulation

• Check if problem behaviour occurs across different contexts (school, family, outdoors) or only in the home à what is the underlying issue?
• Consistency of problem behaviours across different contexts suggest a disorder (e.g. biological causes)
• If it’s happening only in the home, then environmental factors may be more important (medication may lose its effectiveness over time)
• Need specific examples in order to formulate

clinical work

My female owner finally saw all her clients for at least one session. This week has been a “full-on” (Aussie slang) week, with 4 new clients, 1 returning client and a parenting group.

My female owner says that she’s in a strange situation, because she is primarily working with parents to manage their problematic child(ren). She had lotsa cognitive dissonance about doing her internship at her present clinic because i) she has no plans to be a parent ii) she does not like children. Tripled with her inexperience, it doesn’t make her very credible, does it?

Anyway, despite the hectic week, she came out of it, loving clinical work (not because she sees other people in misery!). In the midst of the parents’ misery/ desperation, my female owner sees hope and love in their eyes. Hope that they are not too late in seeking help and love so great, that they are willing to invest time, effort and money to do something about their children. Even the anxious adult client who has been suffering from anxiety for the last 12 years said that he wants to “start living, and not just exist”. Such powerful and hopeful words, from someone who has had to cope with long-term unemployment, physical conditions and psychological distress.

She also realised the power of words spoken in due season. My female owner has always felt that talk is cheap (you know, the “action speaks louder than words” concept). She had been disappointed many times by you-know-who who promised that he would do certain things for her (even simple things like checking out the price of something) only to realise later that the promised deed was not done. So, she rather just do things, without saying anything. Of course, that led to other complications like being labeled as a cold fish or not contributing at work (“need to manage your boss”).

Anyway, as I was saying, yah, my female owner would pray for her clients, asking God to equip her with the right skills and words to speak to their situations. She started to speak words of encouragement to her clients (especially the mothers) to help them see the good that they have been doing. A lot of them blame themselves for their children's behaviours.

It’s amazing to see how simple statements that affirm the hard work they are doing and that reflect their sentiments can enable two strangers to connect and allow the clients to confront their parenting issues more openly with their partners.