Compulsive Floating

It seems like ages since the last time I set time to have a private time with my Reflective Diary. The Autumn term was an amazing transition for me, a step from Graduate Certificate to MSc year. Nearing the end of 2010, I would like to take a lift to explore the changes inside and outside of me, in relation to my personal and professional journey I'm venturing.

I realise my default position in life is floating. I feel calm and at ease with myself most of the time, at times too comfortable that it becomes a compulsive stagnancy - not wanting to get out of bed, playing repetitive computer games like Hearts or Blackgammon non-stop, delaying time to go toilet despite the call of nature or walking to the kitchen to refill my water bottle even when thirsty. There was also a few days in November when I felt rubbish and wished I need not go for appointments scheduled with clients the following day. A familiar feeling that I had before when I was working in Singapore. My default strategies back then was to turn up late for work, chose not to see clients for the whole day or hoped that the client cancel the appointment. What has not changed though is that this feet-dragging feeling evaporates whenever I am in-session convening the therapeutic discussions. The sense of fulfillment usually last for a while after each session but eventually it would revert to a drag to write the casenotes and anticipation of not wanting to go for the next appointments. One strategy I had back then in Singapore was to commit myself and client to a definite date for the next appointment. Penning it down in my diary and verbalising it to the client set as a speech act, an external control for me to commit despite the feet-dragging feeling.

I notice that this feet-dragging feeling lasted for quite long period of time in Singapore; whilst over here it only lingered a few days and disappeared. One major difference is that back then the caseload was over 30 active cases, whereas at this moment, it is only about 6-10 active cases. Flight and staying afloat elsewhere seem to be my coping strategies when I feel overwhelmed.  I believe this survival instinct became part of me during my adolescence when I was at the same time seeking yet running away from myself and my relationships, especially with my parents. This escapism turned into frustration when I felt "pricked" by others, or panic and anxiety when I hear other's feedbacks as criticism, or when I  faced with the reality of deadlines or a backlog of overdue tasks to complete.

Efficiency is one of my key new-year resolution to fight my Compulsive Floating. I also see it to be the key tool to ground me from running away when feeling overwhelmed. It takes quite a bit of determination and planning beforehand in my mind - thinking ahead little steps and the sense of urgency while doing the actual task.  I already see a glimpse of this happening to me in the past months.  It does need some level of external pressure and encouragement for this to happen. One example is the requirement for casenotes at my clinical placement to be entered in the computer system within two working days and my Supervisor's trust in me meeting this timeline and my own (and her) witnessing me doing it brief and fast. I have been able to be on the ball and writing the casenotes  sor far almost immediately after each session for the past month.

Barry Mason's concepts of relational risk and being creative inspired me to play the computer game Hearts differently once. The aim of the game is to either win all the Heart cards and Queen of Spade, or to totally lose all of these 14 cards to other players. I created totally different emotional experiences and journeys when I asked myself, "what if the rule of the game remain unchanged for others, but I changed it for myself?" That liberated me to feel a sense of achievement when I aimed to "lose" the game or when I decided my aim of playing is to enjoy the process of it. I think this is an important experience that informs me to dare myself to think on my feet and aim to go a different direction from my conventional way of facing challenges in life or in my clinical work, eg. the next time I dragged my appointments when my caseload were to shoot up to beyond 10 families, where appropriate, I could start some of the sessions with asking, "I felt overwhelmed recently and had thoughts of not turning up for our appointment today, I wonder if you feel the same at times? I think what made me come is [said something I see as a strength in the family]. What could I possibly say or do wrong today that may make you feel reluctant to come again for the next session?" Or I could use my experience of changing the rule of the Hearts game by telling myself, “Right, what if I were to imagine that I’m going to attend the session not as a therapist but an active audience participating in a small but important page in the development of the family’s life story? It could be fun or dreadful but I’m willing to give it a shot!”

Afternote: It was not Compulsive Floating that defeated me for the past month but my decision to priortise in other aspects of my coursework. It is a month late but I managed to edit and have it published in the end!

Positive Stories of My Genogram

I enjoyed yesterday's Personal and Professional Development session a lot - an exercise for us to share positive aspects of our own genograms (a clinical term for family trees). I was amazed at how cross cultural family relationships and experiences could be! An unplanned common thread among us was about our fathers.

My father grew up in a big family, the fourth of five sons. When he was a child, he was often the first person to be blamed and physically punished by my paternal grandfather whenever something went wrong in the family. According to my father, most of the time he was not responsible for the mischiefs or the occurences! I believe this childhood experience had such huge impact on my father that when he himself became a father, he was determined to be totally different from his own father. The clinical term I could relate this to would be what John Byng-Hall  labelled as a corrective family script, i.e. a guide to actions taken in family relationships that is the total opposite of what was done in the previous generation. 

Througout my childhood my father never used corporal punishment on any of his children. There was only once he lost his temper with me. That was a morning when I was in primary one when I felt really lazy and not wanting to get out of bed. I told him I did not feel like going to school. He was so furious that he took my school uniform and threw it onto the floor. I was so shocked to see him angry with me that I went to school that day.  I never played truant throughout my school days (well of course not counting my college days:). That was the one and only time in my childhood when I experienced my father losing temper. It was not even projected at me but directed at my school uniform!  I could still remember  this incident after so long,  imagine how traumatic it would have been for my father when he was a child or for children who experienced much worse, such as witnessing or experiencing domestic violence.

In a way, I feel priviledged that I was spared from the negative childhood experience my father went through. It probably took lots of conscious and efforts at his end as a parent to refrain from adopting my grandfather's parenting style. I personally do not think that my lack of traumatic childhood hinder my clinical practice. On the contrary, it provides me the strength and curiosity to explore such themes with clinical families without unnecessarily triggering any personal scars or memories that may cloud my clinical neutrality or judgement.

Blog or Block?

One full year of integrating my private reflection and clinical learning with the public domain has been very fulfilling. Yet at the same time I wonder if I have compensated too much on those aspects that are too private to be shared publicly, yet pertinent in my learning process? Also, discussions with new people in this new year made me realise protecting confidentiality of clients in the public domain goes beyond just using pseudo-names or changing some storylines or details; it has to be done in such a way that they themselves and those who know them would not recognise when they read the entries. With these concerns and considerations, I've removed past entries that have direct references to clients. Moving on, my blog will be restricted to only reflection pertaining to my personal and academic learning.

Same-sex Connections

Pic 1: Fisherman's Wharf, San Francisco, 2009

Siegel: For heterosexuals, generally speaking, a supportive family is a given... [For g]ays and lesbians... [e]ven... if...  families in which a gay member is completely and lovingly accepted, where his sexuality is no more an issue than his age or his hair color, he is still alone among family members with his feelings about who he is and where he fits into the larger society... He cannot help but know that the members of his family felt a profound sense of loss upon their discovery of his being gay. His being - who he is - saddens his family. Even when a family evolves through a process of acceptance of a gay or lesbian member, they work themselves through the stages of loss and grief, as does the gay family member.

Walker: I would like your ideas on how straight therapists could be sensitive and helpful to the gay person coming out to the straight family...

Sigel: ... The process of coming out starts with a self-awareness... [i]n most cases, gays and lesbians are dealing with so much negativity from the outside world that some amount of shame exists as part of their experience. Managing both their personal and public responses to feeling or being shamed should be part of the therapeutic preparation for coming out to family and friends. Coming out publicly should represent the culmination of dealing successfully with developmental issues.

...

Siegel: When a family member or friend says to a gay person upon disclosing his homosexuality, "I still love you," it generally means I love you despite your homosexuality.

 Walker: ... what you are saying is that you have to be comfortable enough in yourself to be able to deal with the pain of that. Yet I don't know at what point a person is strong enough to challenge the implications of "I still love you."

Siegel and Walker, 1996: 56-57

Pic 2: Two embracing women, Victoria and Albert Museum, London, 2009

I was quite touched reading this conversation between a gay and heterosexual therapist. The quote abstract above summarised well lots of the pain individuals and their families have to go through. I can also see the paradoxical and interconnected positions faced; the closer the gay person is to the family, the higher the need to "come home" (coming out to family), yet the more disclosures were to be made, the more possibilities of both ends experiencing loss and grief. Unavoidably there are influences from the wider context of the family and societal values, often passed down over generations. This is especially apparent whenever conflicting lifescripts (what one defines onself to be) or cultural values and beliefs become the highest level of interactional contexts, eg. a daughter who identifies herself as lesbian whilst her family believes there is only one way for a woman to lead a happy life - marry a man and have children (doesn't this sound familiar? A challenge faced in societies fighting for women's rights and gender equality? The difference though is that even if she were to divorce or remain single for life, she could still be deemed to be better off than  being a single or coupled lesbian). The more one end pushes the other to accept and agree with oneself, the more the other would retaliate or oppose. This is analagous to the equal action/reaction law in Science, or the political fights we see in the world that often results to violence and war. I think this is quite a natural phonemena from a systemic point of view too - for change is resisted if it is perceived to be imposed by "external forces" eg. daughter seeing her family's rejection of her sexual identity as a  heterosexual oppression, or the family labelling lesbian identity as a "Western" influence and not part of an "Asian" culture. Both are very strong positions soaked with strong feelings, so strong that direct challenge or drawing on facts to refute would not shift either end anywhere nearer to each other.

I could still remember how emotional a guy Z was at the private event of IndigNation 2008, Silence and Aching Hearts. Z was saddened by the fact that his parents were still unable to fully accept his sexual identity even after he came out to them many years ago. The late Mr Anthony Yeo and Mrs Juliana Toh, the family therapists on the panel, consoled him that it does take a long time, just like it took him a long time to accept himself; what would be helpful is to focus on building up the relational closeness with them despite their different belief systems. I could fully appreciate their words now; what it takes for change to occur often is to turn the highest level of interactional context from culture/ lifescript, to relationship, i.e. instead of  fighting for the other end to hear you shout "you have to accept me!" focus on building mutual understanding, respect and trust. Not an easy wheel to turn though, as there are often intense feelings that are like rocks blocking the wheel, rocks of anger, guilt, shame, fear, blame, etc. It does not help to add more or throw more rocks at the wheel, at the same time it is often tough for one to let go of these battles, beliefs and feelings.  When the rocks are simply too heavy and too many, could Z and his parents (and many others in similar situations) leave the wheel  behind instead and walk the rest of the journey together? 

Pic 3: Hanoi, Vietnam, 2005. Same-sex love, a "Western" influence, an embedded "Asian" culture, or both?

The next reflection came through a connection I had  in early 2009 with two family therapists in Singapore, which had personally helped me a lot. This may be more of an Asian cultural issue but I suspect it could apply to other cultures as well, especially in this global village where younger generations grow up with multiple cultural influences. Most Asian parents play more of  a “caregiver” role to their children,  providing basic needs and care,  yet many children today grew up experiencing the loss of wanting parents to be  more than just caregivers but “parents” who could share with their children in-depth social and emotional bond.  How much sense does it make for a gay or lesbian person to come out to his/her "caregiver", or the "caregiver" to confront the gay or lesbian person, when their daily interactions  hardly move beyond exchanges about physical health, food and care issues? If "coming home" is inevitable or occur unexpectedly, how could the relationship be elevated beyond caregiving and to an emotionally close and safe level first? Where are the family or community cushions that could one party or both rest on while both ends grieve and heal? Could love be embraced despite differences and persistent familial and societal prejudices? Do family therapists and other helping professionals see a role in improving our compassion, sensitivity and competency in working through these challenges with our clients and patients?

- written on 13 Aug 10, edited on 3 Oct 10

Pic 4: Brighton Beach, UK, 2010. Just as Dr John Corvino said, could we judge other people not by who they love, but whether they love?

References

Connections. In: LAIRD, J. & GREEN, R.-J. (eds.) Lesbians and Gays in Couples and Families. San Francisco, California: Jossey-Bass.  (Siegel and Walker, 1996)

New Stories about Personal Agency

Reading Freedman and Combs (1996) reminded me of my days as a volunteer counsellor, how I felt powerless whenever I encountered clients who talked about problems that were not within their locus of control, eg. societal perspectives about homosexuality, what kind of parents they have, etc. I would always try to get them to see how pointless it would be to focus on what is beyond their control and look at what is within. Reflecting back, I had probably made them feel belittled or small. Now I could see that there is never such a clear distinction between what is internal and external locus of control; they are interconnected in multiple ways. In fact, having clients who externalise problems is a good opening space for exploration of how they could deal with the problems as a separate being, eg. the "society's problem" rather than "I am the problem". 

There have been people (including myself) wondering how systemic is Narrative Therapy when it often favours stories from one person's perspectives but wait a minute, isn't the very act of helping a person externalise the problem an approach that work with the person and problem as if they are two separate members of a system? I think this is the same argument for working systemically with an individual - exploring his inner world and this relationships with the outside world.

I think Coordinated Management of Meaning (CMM) goes an extra mile. It not only look at stories from a person's perspectives but also from how stories are formed through the social interaction between two or more people. This implies that the moral positions and sense of responsibilities to the stories told through a therapist-client conversation could evolve overtime. Both Narrative and CMM models see that the very act of speech is itself a commitment of seeing or doing things in a different way.

This thought bring me back to the impact of the final group supervision I participated end last month. It was a closure session for the Children Mental Health family therapy clinic that was terminated. During the session I asked - couldn't we manage the challenges ahead by being flexible and versatile? Being in an environment that lacked understanding and support of family therapy and systemic practice, we could continue to practise what we believe in and be the ones to nurture and influence others, in hope that in the near future attain a ripple effect?* Group supervisor's reply was that the problem with being too flexible is that overtime, our passion and ideas would be washed away by other people. I felt quite perturbed by her reply then. Days after, her answers began to make sense to me. I remember the days when I first started my first direct social work full-time job working with at-risk and offending adolescents and their families. How enthusiastic I was in believing I could make a difference. To date I do believe that I had made some differences, yet a larger part of me, overtime, simply adapted to the system, or should I say, was recruited to become part of the muddle?

Through the supervision conversation, I felt our group supervisor had helped to pull us together to a balanced position. I will bare in mind my key takeaway - the need to keep a semi-permeable boundary; to continue to keep like-minded people close at heart to co-construct empowering stories for ourselves and our clients, yet at the same time stay in contact with the not so like-minded ones to keep in touch with the contextual interactions and events. Whether or not this constellation of interaction makes a difference at a wider context, I believe is a matter of time. 

* Recently read the 110th issue of Context, Aug 2010 and understood that that the essence of systemic practice is to cross-fertilize such practices to other colleagues or settings such as social care, education, etc. 

References

FREEDMAN, J. & COMBS, G. 1996. Questions in Action. Narrative therapy : the social construction of preferred realities. New York ; London: Norton.

Strange Loop

Find this quote really apt in describing many great divides within individuals, groups and the wider societies when it comes to issues pertaining to  social issues such as racisim, terrorism, censorship, sexuality, etc, issues that are often interconnected with one or more of the Social GRRAACCEESS, i.e. Gender, Race, Religion, Ability, Age, Class, Culture, Education, Ethnicity, Sexual Orientation, Spirituality (Burnham et al, 2008):

"The strategy that members of the community used for managing experiences of discomfort was one of enacting a feeling (of fear) rather than speaking about it and exploring (and developing its meaning). This fragmentation precipitated a strange loop of oscillating encounter and withdrawal. The fear that was associated with encounter was thus temporarily but not permanently disposed of... The difficulty was connected to a problematic shared belief that conflict was problematic... fear of a lack of shared vision had meant that discussion at the level of vision and strategy never took place in any grounded way. Behaviours that seemed to indicate extreme differences became feared as representative of divison and incommensurability; fears bred more fears."

quote and diagram (Oliver, 2004:132, 138) 

It resonates a lot with the Milan Team's and Bateson's idea of paradox/ doublebind and Motivational Interviewing ideas of ambivalence and contemplation. 

When would individuals, groups and societies put aside fears and blames? I believe it will take a critical mass of people to come together working towards a common stake (Tan, 2005). Love this quote too, "Focusing on ones own vulnerability makes one more attractive to the other and paradoxically helps to build strength." (Oliver, 2004:136). 

References

OLIVER, C. 2004. Reflexive inquiry and the strange loop tool. Human Systems: The Journal of Systemic Consutlation & Management, 15, 127-140.

Burnham, J., Palmab, D. A. & Whitehouse, L. 2008. Learning as a context for differences and differences as a context for learning. Journal of Family Therapy, 30, 529-542.

Tan, C. K. 2005. Loving Myself Workshop. Singapore: Oogachaga.

OVERVIEW of LEARNING and DEVELOPMENT

Scotland, 2010

 “The map is not the territory”[1] – a systemic term apt to describe my struggle to summarize a year’s learning within word limits. Yet there is a need to tell better stories within the constraint of the real world (Pocock, 1995). While there are multiple ways to do this, I decided on the following:

Clinical and Academic Changes

Present of Past Memory[2]

Even though I learnt family therapy theories in my Social Work degree, I forgot most details because of the lack of opportunity to apply in practice. The closest I got subsequently was from my full-time job opportunity in early 2009 when I was oriented via a short USA study trip to the Multisystemic Therapy and Functional Family Therapy. My volunteer work, on the contrary, gave me more exposures; learning from a workshop the application of Structural model for same-sex couples (Greenan, 2009), reading books/ papers such as Greenan and Tunnell (Greenan and Tunnell, 2003), Tomm’s Interventive Interviewing ((1987a, 1987b, 1988) and Pearce’s Coordinated Management of Meaning (CMM) (2004), as well as group supervision experiences of Reflecting Team and Internalising the Other. My understanding of the concepts, however, remained superficial.

Present Perception¹

Academic

Three learning outcomes[3] I am pleased with:

1. An ability to explore and give account of personal learning over time

Self-rated increase from 7 to 9

Being able to sustain this in writing and discussion consistently overtime and feeling less anxious or overwhelmed by details, lack of time or discipline at times!

2. An ability to place the development of family therapy in an historical context

Self-rated increase from 2 to 8

3. An ability to describe differences and similarities between approaches in systemic therapy including the theory of change.

Self-rated increase from 3 to 7

The exam preparatory process, especially, pushed me to gain clarity to both 2 and 3,  such as Family Life Cycle, Transgenerational, Milan, Post-Milan, Structural and Strategic Models.

Clinical

What I found most privileged is having the placement that exposed me to three different settings, from children, adults to older adults mental health services. I appreciate my supervisor’s receptiveness to my attempts to apply theoretical learning such as Transgenerational coaching, circular questioning and reflecting conversations, as well as demonstrating her Narrative approaches. I am also encouraged by her support and active participation in my self-reflexive exercises through supervision, case discussions and commenting on my blog.

Coming from an English language-based education in Singapore, language is not an issue for me in therapy work. However, working primarily with British-White families in this placement, I faced some difficulties in understanding some accents and topic of interests that families referred to that maybe very British culture specific. While I dealt by pretending I understood or relying on my supervisor to engage in these conversations, I hope to be more honest and independent in the coming year, especially if I were to face a more culturally diverse clientele, to situate myself in a more comfortable position of not-knowing and use it therapeutically, either as a form of curiosity for further questioning or applying Burnham’s relational reflexivity (2005).

Present of Future Expectations¹

Academic

Three areas I feel I need further work on at the MSc Level:

1. Familiarity with a broad range of literature relating to family therapy and systemic practice. I hope to read not just specific journals, but more original sources of the approaches.

2. An ability to evaluate critically some areas of relevant research. As mentioned in my reflection on research, I am still guilty of skipping the parts of methodology and results!

3. Knowledge and skills required in engaging a range of client groups and working with them effectively. I hope to know more about CMM and integrated approaches to work with Social Services and families with same-sex individuals/couples, such as unbalancing, interventive interviewing,  relative influence questioning, etc.

Clinical

I appreciate my supervisor’s pacing allowance for my slow progression from an observer, a reflecting therapist, a co-therapist to eventually a lead therapist. I became aware I had been overly dependent on her as the lead therapist during a session in Jun 2010 when I was asked to be the lead therapist. I felt incompetent when leading the initial engagement and small talk with the family despite – very basic aspects of therapeutic relationship that I had taken for granted as a co-therapist! This reminded me of my role in my family, being the youngest, often reliant on my parents and siblings to initiate talks and make decisions. My past work and volunteer experiences had made me realised that when given the responsibility, I would be able to take up leadership role overtime. This is demonstrated in my ease and competence in taking the lead in the same month with another family I have been seeing for seven months together with another therapist. Moving forward, my challenge is to build and sustain confidence for initial engagement with families I am new to.

Scotland, 2010

 Personal and Professional Changes

A review of my personal and professional changes through the lens of time categorised in three segments:

Oct- Dec

I started this learning journey questioning myself about risk-taking and picked up the term “de-skilled”; I liked my description of this as the need to feel naked before donning fresh clothes. What inspired me initially was how quick and apt two seniors, within the first hour of knowing me at the first Personal and Professional Development (PPD) session, helped create new meaning to my use of planning skills as an overcompensation of my lack of self-confidence, yet I was often impaired by my anxiety and lack of prioritisation. In a way it is a projection of a level of clinical sensitivity I hope to attain in a year’s time when I reach their MSc level.

Jan-Mar

January was the official “launch” month of my blog online. I purposely chose to publish entries two months later to allow time for post reflection and editing. Publishing my clinical learning points and reflective diary on a public blog challenged me to strike a balance between maintaining professional confidentiality and recruiting “witnesses” in my learning, especially with those interested in systemic practice and hopefully extended beyond the geographical boundary of London.

There were more reflections of my academic learning including research, Structural and SFBT models. These are rather impersonal aspects of me, just like the way my coursemates’s first impression of me - being “technical”, which I agree! A more most personal portion is the record of my therapeutic letter to my Genogram I wrote at a PPD session, the only part of my whole journal that I explicitly mention about my family. While  I felt I have  known not much more than what I already know about my family before I started this family therapy course. I experienced a difference in my interaction with my parents during my vocation back home late December, which I chose to share at PPD but not in my reflective diary. This is out of respect for family, who have high regards for privacy thus it would not be appropriate to disclose too much in my public blog. This certainly creates a paradox for me, wanting transparency yet retaining parts of it opaque. I chose to reflect the more sensitive portions separately with only my tutors and course mates in two of my academic assignments and reflections of tutors’ comments. 

Scotland, 2010

I also reflected about time drawing learning from my tutor’s Academic Seminar about Time. I noted my learning enthusiasm dipped six months after starting the course. This, I reflected, was because of my disappointment from the lack of experiential learning experience (apart from the clinical placement) I preferred. In March I saw a leap from that “rock bottom” when I grasped the more recursive process of inputs (observing, listening, reading) and output (mainly writing and reflecting).

Apr-Jun

This part of the journey maintained the more “technical” side of me, with further reflections on academic learning, such as systemic work with an individual, questioning techniques and integrating ideas. I especially like this portion:

1. Very often I tend to jump straight to think what therapeutic techniques to apply at what point of a therapy session or with which client, eg. use scaling question, circular question, etc. What’s often missing, is the conceptualizing stage - what theoretical ideas and cues gathered from clients that inform me what to say or do, aptly described by a course mate as “putting the thinking behind the doing”.

2. The process described above may come rather intuitively or too fast for one to be aware immediately. In fact, the thinking often happens in retrospect. This post realization is important too, most clinical models are created from what clinicians did in practice to begin with anyway.

I have never been able to register these three terms Perceptual, Conceptual and Executional skills my tutor taught because they are really long and hard to remember. I derived the chart below instead to help myself remember in more simplified words: See May 2010 entry.

The final reflection in June was an unusual one – the politics experienced by the family therapy team I had my placement at. There were feelings of anger and injustice during the incident but post-reflection helped to surface a sense of relief and appreciation for the valuable learning experiences.

Overall, I could now see my learning process not as a linear but a circular process, always returning to the original point where I started, just like walking one round a park in Autumn, Spring and Summer. I am still who I was who started the journey but loaded with more photos of memory and experiences, in preparation to begin another walk around the same park but with more familiarity and wider perspectives to navigate and explore.

Scotland, 2010

 

Bibliography

BURNHAM, J. 2005. Relational reflexivity:  a tool for socially constructing therapeutic relationships. In: FLASKAS, C., MASON, B. AND PERLESZ, A. (ed.) The space between: experience, context and process in therapeutic relationships. London: Karnac.

GREENAN, D. E. 2009. Same Sex Couples - How Practitioners Can Help. Singapore: Oogachaga Counselling and Support.

GREENAN, D. E. & TUNNELL, G. 2003. Couple Therapy with Gay Men, New York, The Guilford Press.

PEARCE, W. B. 2004. The Coordinated Management of Meaning (CMM). In: GUDYKUNST, W. B. (ed.) Theorizing about Intercultural Communication. UK: Sage Publications Ltd.

POCOCK, D. 1995. Postmodern Chic: Postmodern Critique. Context, 46-48.

TOMM, K. 1987a. Interventive Interviewing: Part I: Strategizing as a Fourth Guideline for the Therapist. Family Process, 26, 3-13.

TOMM, K. 1987b. Interventive Interviewing: Part II. Reflexive Questioning as a Means to Enable Self-Healing. Family Process, 26, 167-183.

TOMM, K. 1988. Interventive Interviewing: Part III. Intending to Ask Lineal, Circular, Strategic, or Reflexive Questions. Family Process, 27, 1-15.

---

[1] An often quoted phrase used by Gregory Bateson in his 1972 book "Steps to an Ecology of the Mind".

[2] Augustine of Hippo, 1961, cited by Jenkins, 2010

[3] Based on a 10-point scale listing 13 learning outcome for the course I was given at the beginning of the course.

Systemic way of looking at "Politics"

I was initially tempted to reflect at length on the office "politics" that have resulted in the plight in the Children Mental Health Family Therapy Team I have been invovled in my clinical placement for the past eight months. There is anger in me over the abrupt managerial level decision for it to stop its therapy work despite it doing well for the past two years and continuing to have demands from referrals. I share the team's frustration that there has been a lack of considerations and thoughts for the best interest of the families in need. 

I changed my mind while reading an interview with Luigi Boscolo and Gianfronco Cecchin, two of the four founding members of the original Milan approach, in the 1989 book entitled "Milan Systemic Family Therapy" (p155):

Cecchin: ... you have to accept the system you're working in as it is, the way you accept the family. You mustn't try to convince your colleagues of your way of working; you shouldn't get into fights with them, because, at that moment, you're not neutral.

Boscolo: When our first trainees went back to their workplaces, they tended to give the message to their colleagus: "We have a new theory that will make you more effective." The result was that they were wiped out.

Interviewer: What if they were faced with a decision to give medication or some other procedure that they couldn't believe in? What would you tell them to do then?

Cecchin: ... of course, you can't be neutral. All you can do is make it clear where you are coming from. For instance, if a person comes in who is breaking windows and acting crazy, you might give them medication and lock them up. Since at that moment you are being paid to be a policeman... you don't say "What's wrong with you?" or "Let's try to cure you." ...

Boscolo: ... [Neutrality is] a position to use only when you do therapy. I remember a trainee who said "I was driving on the highway and a car came up behind me and hit me. It was hard to find a positive connotation, but I did! I said 'This will help me to be more alert on the road.' " You have to protect yourself by protesting and getting angry; otherwise you won't collect any insurance.

I think the above discussion resonates a lot with the situation our team faced. At the wider context of how the team was formed and sustained, it is not surprising that in a setting where the decision makers were not supportive of systemic approaches to begin with, they would have felt  threatened by its success and would choose to "wipe it out" when the opportunity comes.  At an emotional level, I recognise that I am not and unable to stay neutral as I had been affected by this change and have only been able to see and hear from the team's perspective of the situation. From my professional point of view, I would see this to be an an unethical practice by the management, yet unfortunately, as a trainee, I am in no position to challenge or put forward a case to "fight". I am, however, comforted by the professionalism of the team, in strategising together alternative ways to hold and sustain therapeutic functions for existing families the team is seeing during this transitional crises.

While writing this now, the anger has ceased and in the midst of revising this one year's studies of systemic therapy, I am appreciating more and more how thinking of systems as a whole, and seeing problems and situations at different relational levels are helpful for me to come to terms with challenges and transitions better. While emotional reactivity in many contexts is regarded as undesirable or unhelpful, when managed well, I think it can still be appropriate to express some of it in real life situation, for it to be heard and safeguard personal and professional positions.

The above is written on 7 Jun 2010. I shall let these thoughts settle for a while, say for a few weeks, before coming back to reread and write some further reflections of this reflection.

29 Jun 2010: Reread the entry above and decided not to amend it, nevertheless, I do recognise what I wrote here is based on my hypotheses, which could not be verified with the management. There would also be as many ways to describe this experience as the number of people affected/ involved, or even more.

 

A Simplified Working Model

Felt there were important discussions we had at clinical skills seminar today that is worth reflecting here, which I hope will be a reminder for my future clinical practice too:

1. Very often we tend to jump straight to thinking what therapeutic techniques to apply at what point of a therapy session or with which client, eg. use scaling question, circular question, sculpting, etc. What’s often missing, which is really important, is the conceptualizing stage, what theoretical ideas and cues we gather from clients that inform us what to say or do? a colleague summarized this really well with this saying “putting the thinking behind the doing”.

2. Many a times, the process described in above may come rather intuitively or too fast for us to be aware immediately. In fact, the thinking often happens in retrospect. This post realization is important too, most clinical models are created from what clinicians did in practice to begin with anyway.

Our tutor has more than once use the terms Perceptual, Conceptual and Executional to describe the process described in point 1 above (and recently I realized there is actually a journal article written by Tomm and Wright about it!). I have never been able to register these three terms in my mind! Think partly because they are really long words that are hard to flash them quickly over my mind. So, I’ve come out with the chart below to help myself remember it using more simplified words:

Questions and Processes

During a video-tape review session in Clinical Skills seminar, I interrupted the discussion by seeking clarification for the difference between two interventive techniques "positive connotation" and "reframing". That question had been troubling me since the earlier part of my course. Answers had been given before in other seminars but each time I was left even more confused. Felt really relieved when this time round the explanations were made once again and I got it!

What I wanted to write about here is not so much the content of this discussion but the process I went through in gaining "enlightenment". I realise whenever I ask a question in a seminar, the answer to my question and the interactive experience of talking about it would always be my key learning. Overtime I grew to appreciate this and understand why my clinical supervisor in Singapore and my placement supervisor now always start a supervision with by asking what questions I have and how I want to make use of the session.

This also leads me to think of a contrast though – systemic therapists tend to focus a lot on questioning, just like Karl Tomm opined that circular questions at the beginning of a therapeutic process are meant more for therapists to understand the problems and the contexts of the problems (Tomm, 1989); if this is the case, would therapists “gain” more than the families initially? Would it be more helpful for families to ask more questions in session over time so that they will surpass therapists’ learning about themselves? I suppose this is what Tomm proposed asking more “reflexive questions” overtime for families to trigger more thoughts about their problems and the contexts. Our tutor also agreed and added that overtime there should be a responsibility shift from therapist to families, and from tutors to trainees.

A further reflection of my reflection above made me think that it would be too constraining to assume that families will only gain from asking questions in a session. For me personally, there have been simple words, phrases and comments made by people in my life, be it a therapist or a friend, that made such great impacts that even today, I could still remember vividly! Of course, whether the words are helpful or not is another question altogether.

There could also be many other aspects of a therapy that have an impact too, for example, holding on to a sense of hope (for change) or just purely the experience of listening to what one would not hear outside of a therapy session because family rules and boundary forbid.

On a separate note, our tutor also highlighted there had been research in couples relationships that found that people pay attention to body language (55%), next the tone (38%) and lastly words (7%). This resonates with what most systemic therapists' emphasie on processes (all three components) rather than just content (words). Yet at the same time, I wonder if social constructionist approaches in systemic therapy could have lost important cues of change if the main emphasis is just on language, i.e. words? This is also Minuchin’s critique (1999). Found it fascinating that he described therapy as more of a drama than a story, the former encapsulates the story and the actors, whereas the latter just the story itself. I could however, see this in another perspective, in which social constructionist approaches focus not just on words, but the meaning behind the words and how they are constructed by the metaphorical and physical structures of the family and the society. Also, some people gain more from reading a book, while others from watching a film. One size cannot fit all! If so,  could a systemic psychotherapist who only adopt one model, one approach, be it say Narrative, Milan or Structural, be genuinely systemic? 

Systemic Therapy with an Individual

Reflection on Systemic Therapy with an Individual

The journal article "Advances in Coaching: Family Therapy with One Person" (McGoldrick and Carter, 2001) illustrated how systemic therapy could be done with an individual. The theoretical basis comes from the belief that with change in one person within a system, there would be ripple effect on others. This "one person" is usually the most motivated and functional member in family.  If this is the case, wouldn't it be more systemic to work with more of than one such motivated persons, if they were available? Would it be more effective to concurrently work individually with the "symptomatic" person in a more intrapsychic model, and eventually when ready and consent given by both ends, do joint sessions? 

In preparation for my interview for my MSc application, I'm also starting to think of some research questions for dissertation in my second year. I have two research questions in mind deriving from here : 1. Which type of systemic therapy with an individual is more effective, one that works with the referred person or a significant other?  2. Does number matters in systemic therapy  - involving how many persons is too few, or too many in a session?
Say, what happens if there are 10 or more family members when there is just limited time (1 or 1.5 hours), limited attention-span and limited space to get round to everyone...

Post-reflection (23 May 10): As I'm reading more about ethics in practices now, I would question myself if the questions I posted above came too much from a rather "expert" position. I would need to put the questions into the relevant organisational, cultural and other contextual lenses to answer them. Also, there would be limitations in actual clinical practice to include more persons in a session, eg. client not giving consent, etc, so it would be helpful to have some idea of what could be done I were to be in the worst scenario of only be able to work with only one person in the system.

Three Reflections in Mar 2010

Rock Bottom (09/03/2010)

It has been six months since I started this learning journey. Time flies!  There were moments in the past months where I felt emotionally low and lost, questioning if I had chosen the right path for myself. Guess I came with high expectations, hearing the almost transformational experiences that I would have from such a course, so there had been some disappointments. On reflection, one key area was my expectation to gain my mind-stimulation through experiential learning, group-based activities and loads of hands-on sessions, constant discussion and being questioned about learning processes and self-reflexivity. Main goals I had - myself growing sharper in reading the moment and more articulate in the systemic way of convening a family session.

I see a leap from this rock bottom in recent weeks. One realization is that this path requires a more personal reflexive space for growth, through the recursive process of inputs (observing, listening, reading) and output (mainly writing and reflecting). I was told that first year is actually more theory-based while the second year there would be more hands-on exposure. Clinical discussion is another key area which I felt is important and could have more, perhaps from informal arrangements from my own initiatives as well.

Find this is good opportunity to review my learning process and what learning “gremlins” I spotted so far:

1.        I’m glad to see that I have not overly spent time in organizing things, though at times things do get rather disorganized. I have learnt to be not overwhelmed by them but periodically sort things out.

2.        A learning “gremlin” reappeared, which I’ve heard exist in other friends’ learning process too; at times I would simply just do anything under the sun other than readings or academic writing, even though deadlines could be close. As compared to the past, I find myself in better control, the gremlins tend to wonder still but at a shorter time span. Sometimes it also helps to see it as “I need to take a break”, eg. play Spider Solitaire, Hearts,  Chess, etc. even though sometimes the break overstreched, it’s okay, as long as I eventually come back!

3.        The importance of being consistent in writing and not to accumulate back log, something which I was mindful when I started working as an aftercare officer but lapsed over the months. This will be a huge goal I am committed to achieve and to gather mutual support from my colleagues! Yes, there are still back log, both in writing and reading. What has been helpful is the learning of speed-reading and letting go of the need to read everything. Rather to read with a purpose and make it interactive with myself or others. As for writing, well, much better than in the days of tonnes of casenotes  accumulating, neverending !but it is also largely because the caseload back then was impossible! Excuses:? hmm...)

A Letter to my Genogram (15/3/10)

At the last half an hour of the Personal and Professional Development (PPD) session, I was tasked to write a letter to my genogram that I drew and shared at the start of the course. This is an idea drawn from therapeutic letters often applied in the Narrative approach by Michael White. My mind was empty at the beginning but was amazed that ideas and thoughts just flow as I wrote! Here’s my letter:

Dear Genogram,

I don’t know what to say to you right now. Saw you at the beginning of this course, shared about you to my colleagues then, but just kept you at the book shelf since.

I remember our tutor expressed his surprise when I presented the pre-drawn you at PPD, as he said it could be risky to draw you alone. Fortunately for me, you were not as "poisonous" as how some other genograms might be.

If I were to look at you again right now, I wonder if you would have changed. My sense is that you would. As the family (past and present) drawing another tutor got us to daw at Cinical Skills seminar two weeks back is the you in dfferent set of clothes – you were wearing autumn clothes and that was you in winter clothes.

What do I notice changed in you? Perhaps the brigher part of you is shining on my life in London.

How would you be different in 1, 2, 5 years down the road? I kind of hope to bring the current you back in my luggage eventually when I return to Singapore for good, or to put you up like a poster in my bedroom if I were to be still in London then.

The colour I imagine you are now is red, a dimly-lit one. I wonder what feeling red expresses – not anger but probably a “stop”, a rest from the bustling life I was leading before I drew you, when I walked the streets of a city with four seasons.

Reflections from Seminars (23/3/10)

Last Friday we had a family therapist working in Adult Mental Health sector to conduct the Academic Seminar. Was really a great session! She positioned herself as a systemic psychotherapist with strong influences from the post-Milan social constructionist.

My key takeaways from the session:

1. The importance for the family therapy team to gain clarity right from the point of referral the following :

o   Who is asking for what? Eg. Referral to family therapy by care coordinator (an equivalent of caseworker in Singapore context) for a married couple, with concerns over the couple’s sexual issues, wife’s mental health and the couple’s parenting, as their only child is in the Child Protection register.

o   What are the systems of concern? Eg. Couple system, parent-child system (with strong linkage with Social Services because of child protection concern), mental health system, etc.

o   Who and how to invite? Eg. Invite as many of those significant in the systems of concern as possible for the first session so as to have a more holistic understanding of the family from as many perspectives as possible. For the first session, social worker, care coordinator, the couple. Child is excluded because of the sensitivity of the adult sexual issues. In the letter to the couple, ask if it were okay for care coordinator and social worker to be invited, and offer for couple to bring any significant others to session they find would be helpful. Collaborative decisions could then be made by therapist and couple who to include or exclude after the first session.

2. The role play at the later part of the session was very helpful, with the psychotherapist demonstrating her style as the therapist. She made a third of us participating in the role play, a third as her reflecting team and a third as an external team observing processes and techniques.  What was amazing is that she not only attained good therapeutic alliance, providing ample attention and engagement with the couple, care coordinator and social worker, but also was able to attain the level of interventive interviewing (having each question she asked as an intervention by itself) by asking and focusing primarily on process rather than content.

3. The inclusion of critical role and perspectives from professionals and referring persons right from the start in the first session is so crucial. Whether or not they continue to be involved in subsequent sessions depends on how closely-knitted that professional is with the family. It also helped the social worker to be able to give a different experience and observatory position to make child protection assessments.

4. The positive impact on clients hearing the reflecting team highlighting strengths and recognizing the clients’ struggles. The relevant professionals could in subsequent sessions join as reflecting team.

Interestingly, during the three-way discussion as my mid-term review of my clinical placement few weeks back, as well as during Clinical Skills Seminar yesterday, people's guesses are that I’m influenced by the Narrative approach in family therapy. In both accounts I clarified that I see myself fitting more with the Post-Milan approach. A colleague and tutor actually opined that I would make a good Feminist therapist too!

Another key point discussed at Clinical Skills is the distinction drawn between my personal approach and the approach(es) that would be most culturally feasible in Singapore. While my tutor and my sense is that Solution-focused and Behavioural approaches are more popular in Singapore, the contextual family approaches such as transgenerational approaches would be very useful too. I shared that many social workers in Singapore are very into the Satir Model too, which I personally was surprised how little emphasis on Satir’s approaches are in the UK family therapy field. For a first time I was given a contextual account of how Satir was initially very influential family therapy but later "sought asylum" in the Gestalt field of individual psychotherapy after some disagreements with some other leading family therapists back then. How interesting, and finally this cloud in my head since the start of this course has been cleared. I'm still disappointed though that not to be able to learn much of her approaches here but I guess there would opportunities in future in other means.