The year 2020 saw a rise in uncertainties. Many have experienced anxiety, job loss, a strain on finances and family relationships due to the impact of the pandemic. By default, couples need to adjust to working from homes, with blurred boundaries between work and family, lesser personal space and challenges in new routines. They may not have readily communicated effectively about their roles, given the constant changes in adjusting to tightening and lifting measures. Coupled with the labour crunch, families may find it increasingly formidable or costly to hire a helper to care for children, who are required to stay home for home-based learning or the care of elderly parents who may be weak and frail. This may inevitably lead to unresolved conflicts between the couple due to the stress and demands of constant transition and change. In 2020, a survey for mums showed that 60% of the participants rated their stress level at a 7 out of 10. In addition, 3 out of 10 of the participants felt sad most of the time.
Children and young people are not spared from the raging wave of anxiety. According to a survey conducted by Focus on the Family, kids are more anxious about exams than Covid 19 (The Straits Times, 18 Sep 2020). However, in an international study of 72 countries (including Singapore), only 6% of teens share their problems with their families (Impact of the Pandemic on Family Life Across Cultures 2020, Namad Bin Kalifa University). No wonder the CEO of the Institute of Mental Health says that “Gen Z faces different forms of stress, maybe more anxious, depressed than others before them (Today, updated on 1 Mar 2021).” President Halimah also urged Singapore to step up efforts to protect children’s mental health early (The Straits Times, 2 Dec 2020).
Given the tremendous stress that kids and adults are facing, families are stretched very thinly. Therefore, they ought to rise above their concern of seeking a mental health facility to deal with their issues early, so that family members can get the professional help they need.
It is timely for the family to consider attending family therapy to address and deal with the mental well-being issues, be it stress or anxiety collectively.
You may have some questions about family therapy, and here are some FAQs that seek to answer your questions.
Why Family Therapy?
Having to deal with unhealthy family dynamics constantly puts a toll on one’s mental wellness.Family therapy focuses on improving family communication; it deals with family conflicts, seeks and creates better functioning and environment. It provides family members with an opportunity to talk about how they think and feel, being affected by the issue they face. It enhances skills to facilitate healing. Therefore marriage and family therapy are essential.
Family therapy shifts the focus from blame, diagnostical lens, linear causality, and looks at circular causality in an issue. For example, a teen who exhibits school refusal may be staying home because of his worry and caregiving role to his mum, who is in chronic health and has a strained marital relationship with her spouse. It helps the family understand the issue confronting them in the family context and the larger contexts, i.e. the pandemic.
Family Therapy is often used to help treat an individual’s problem that has dire effects on the entire family, i.e. depression, anxiety and behavioural issues. This type of psychotherapy is also helpful in addressing family-centric problems, i.e. conflicts between spouses, siblings, parents and children.
What is Family Therapy?
Family therapy is psychotherapy designed to identify family patterns that may have contributed to behavioural or mental well-being concerns. The idea is to help family members break those habits as the family therapist involves the family in discussion and problem-solving.
What can I expect when my family and I attend a Family Therapy session?
During family systems therapy, the family therapist works individually and collaboratively to resolve their issue, which directly affects one or more family members. Each family member has the space to say what they think and how they feel as the issue affects them. For example, when a teen has anxiety issues, a family member gets to talk about how this issue impacts them.
How long is each session and how long is the therapy period?
1.5 hours per session over a period of 4-8 sessions, subject to review with your family therapist. Family therapy is a specialised counselling process. No one is a miracle worker. It takes time and commitment for the family to work through their issues.
Are family therapists trained?
Yes, systemic family therapists are trained with a Masters in Family and Systemic Psychotherapy, a specialised skills competency in systemic couple and family work. It draws on systems thinking and views the family as a unit. It evaluates the parts of the system (individual) in relation to the whole (family) and examines how an issue of one or more members of the family affects the whole family. It suggests that a family member’s behaviour or issue may be embedded in the family dynamics and influenced by the family of origin issues.
Family Therapists would have undergone at least 560 hours of academic instruction and supervised clinical practice, accompanied by years of experience.
When should my family and I attend Family Therapy?
It is always helpful to seek family therapy early before the issue snowballs and becomes more difficult or complicated to manage at the later stage.
Who should attend Family Therapy?
Immediate Family members in a family nucleus should attend Family Therapy, i.e. couples, parents, children (includes teens and adult children) siblings.
Does my whole family need to attend? What happens if I am unable to get all my family members to attend Family Therapy?
It will be helpful if your family can attend therapy together. However, it is okay if not all family members can turn up for therapy. The family therapist will collaborate with the members who come for therapy sessions.
How do I prepare for Family Therapy?
Discuss with your family members about attending therapy together. Think and write down what you want to discuss before each session. Then, ask your family therapist how you want to improve the communication in the family.
Is there confidentiality?
Yes, the session is confidential under the Singapore Data Protection Act 2012 (“Act”).
Therapy is an indispensable tool to recovery, or in helping one gain deeper insights and achieve self-actualisation. In light of the ongoing COVID-19 pandemic, traditional face-to-face therapy has been forced to take on various forms, including sessions conducted via telephone or through video-calling platforms. Of course, therapy serves the same purpose, regardless of whether it is conducted in person or otherwise. However, there is definitely something restorative about being able to connect with a therapist physically. Humans are innately social creatures after-all, and sometimes when things get tough, a little more human interaction and comfort can go a long way.
Physical presence in therapy certainly provides a deeper sense of connection, in contrast with virtual therapy where one might feel more distant and detached. It may seem bearable at the very beginning, but as you progress through the sessions, having to interact with your therapist through a screen all the time can get frustrating. Similar to how students may have trouble coping with online school and home-based learning, virtual therapy has some form of hindrance when it comes to relationship-building with your therapist. For most psychotherapy methods, it is indeed possible to shift them online. However, for others such as psychodrama, it may not be entirely ideal. How expressive and comfortable can you get, when you’re struggling to follow your therapist’s directives through the small screen and having to deal with technological lags?
Seeing your therapist in person also allows for him/her to detect any subtle body language and somatic movements. These are all non-verbal cues that may be lost through telecommunication. Non-verbal cues are just as important as verbal ones, and can provide your therapist with greater insights. Non-verbal signals can serve to convey your feelings along with what is being said, and can either reinforce or contradict verbal messages. Ignoring them would be very much a failure to be fully engaged in a conversation. Moreover, seeing you in person provides therapists with the ease to identify any form of dissociation. During the session, clients may not necessarily attune well, and may not be fully present in the moment. The client may be engaging with the therapist, but seemingly thinking about something else that is going on in their life at the same time. This does not mean that the session is unhelpful or “boring”. While this could simply be attributed to the lack of presence, it could also point towards other concerns regarding the client’s state of mind. Fragmentation can occur especially when one is recovering from a past trauma and can be brought to the forefront, causing incomprehensive emotional reactions when triggered. Fragments of self are usually suppressed, often attributed to the lack of a sense of safety when it comes to expressing their inner needs or desires. When these feelings start to show during therapy, therapists can identify them through common tell-tale signs such as a switch into dissociation, noticeable body movements (twitching, scrunching of fingers or toes etc.). Body language is not definitive, but can offer clues about one’s thoughts and feelings. With telecommunication, it is more often than not impossible to see the client below shoulder-level, thus making it difficult for therapists to assess any somatic movements that may be occurring.
Another issue with telecommunication is the lack of control over the therapeutic environment. In a traditional face-to-face session, the clinician has considerable control over the environment, and is able to ensure a private, safe and quiet space for the entire duration of the session. This limits the number of distractions and allows for both the therapist and the client to concentrate on psychotherapy. Moreover, in a clinical setting, furniture is often set up in particular ways to facilitate clinician-patient interactions. For instance, seats may be arranged such that the clinician would be facing the client at an angle of 45 to 90 degrees, and approximately 2 to 3 feet away. Facing the client directly can feel somewhat threatening for some, and this angle allows for the client to feel more at ease. Additionally, it allows for both parties to break eye contact naturally (intermittently) without seeming antisocial or distracted by having to do so actively. In contrast, having a session online or through telephone allows for less control over interactions and the client may be more exposed to external distractions or undesirable interruptions. This also leads us to our next point, where teleconsultations also increase the risks of privacy breaches.
Due to the lack of environmental control, having a consultation via telecommunication methods can be a challenge especially for those who do not have access to their own private space. For individuals living with others, there could be situations that compromise client confidentiality, including potential eavesdropping or having others walk in on them. Not only does this make the session extremely disruptive, it can be a huge concern for many considering that mental health concerns are sensitive topics. Clients must make the extra effort to find a suitable place and time for them to speak with their therapists freely and with ease. As such, physical presence in a controlled clinical setting may have the upper hand.
Nevertheless, this article in no way aims at undermining the efficacy of tele-health, nor to allude that tele-therapy is ineffective or pointless. Considering the need for physical distancing during the pandemic, telecommunication is undeniably crucial in limiting the spread of the virus. Putting that aside, traditional in-person therapy can have its barriers too, limiting people from attaining the mental health support they need. Individuals with disabilities may find accessibility to be a significant problem at hand, and find it difficult to travel for therapy without having others to rely on. Others include parents who are unable to find suitable childcare options, all while juggling work and mental health care. For those struggling with social anxiety and agoraphobia, it can also be extremely intimidating and overwhelming for them to step out. In fact, some research has shown that virtual and in-person therapy, depending on the treatment goal, can be equally effective. In adults, cognitive behavioural therapy was shown to be similarly effective both in vivo and virtually (Khatri et al., 2014). There is also evidence that youth with anxiety disorders respond positively via telehealth (Khan et al., 2020). Traditional face-to-face therapy and tele-therapy both have their perks, and we acknowledge that it also boils down to individual preferences. If you’re unsure as to which treatment option to opt for, do feel free to contact us.
Brenes, G. A., Ingram, C. W., & Danhauer, S. C. (2011). Benefits and Challenges of Conducting Psychotherapy by Telephone. Professional psychology, research and practice, 42(6), 543–549. https://doi.org/10.1037/a0026135 (Accessed 06/09/2021)
Khatri N., Marziali E., Tchernikov I., Shepherd N. Comparing telehealth-based and clinic-based group cognitive behavioral therapy for adults with depression and anxiety: A pilot study. Clinical Interventions in Aging. 2014;9:765. (Accessed 09/09/2021)
Khan, A. N., Bilek, E., Tomlinson, R. C., & Becker-Haimes, E. M. (2021). Treating Social Anxiety in an Era of Social Distancing: Adapting Exposure Therapy for Youth During COVID-19. Cognitive and behavioral practice, 10.1016/j.cbpra.2020.12.002. Advance online publication. https://doi.org/10.1016/j.cbpra.2020.12.002 (Accessed 09/09/2021)
For many people, when they hear the word ‘Psychiatrist’, it would instantly conjure up an image of a doctor prescribing medicine for someone with a mental health condition. This is true to the extent that a psychiatrist is a medical doctor who has undergone training to become a mental health specialist. While prescribing medications are indeed part of the treatment process, what really goes on in between – from the first session to the very end?
On your very first session, your psychiatrist will most likely spend 1-1.5 hours with you to gain a better understanding of what you’re coming in for. Mental health conditions can be a touchy subject for many, and it is understandable that you’d feel hesitant to open up to a complete stranger right away. However, trust that your psychiatrist has your best interests in mind, and will do his/her best to provide optimal treatment. Don’t be afraid of being judged for your symptoms, rest assured that the psychiatrist’s office is a safe and non-judgemental space. The psychiatrist will want to know as much as you’re willing to share, and being honest with your psychiatrist will be extremely helpful for an accurate diagnosis and the development of an effective treatment plan. Just as what you’d expect when you seek a General Practitioner for physical conditions, your psychiatrist would start off by asking broader questions such as, “What brings you here today,” or “How can I help you?” For some individuals, especially if it’s their first time at a psychiatrist’s, open-ended questions like these may be nerve-wracking. You may feel a little overwhelmed, not knowing how to start or where to begin. However, there are no hard and fast rules as to how the session should flow. Simply communicating your symptoms and your concerns would be a great start, and your psychiatrist will guide you through the interview.
Your psychiatrist will also run through a history-taking process, paying special attention to your medical history, family history, your current lifestyle habits and general patterns of sleep. It is important to let your psychiatrist know if you’re on certain medications, as some may have side effects that may fuel certain mental health conditions. Avoid downplaying or dismissing any information related to your physical or mental wellbeing, the clue to an accurate diagnosis may very well lie in the details. As such, going for your first session prepared with a complete list of medications, dosages, and your compliance with them can be very beneficial. Many studies have also shown that genetics play a role in mental health disorders. If you have a family member who suffers from a psychiatric issue, be sure to let your psychiatrist know for him to have a clearer idea of the situation. If need be, your psychiatrist may also ask permission to speak with other family members.
Depending on the patient’s circumstance, the psychiatrist may conduct a physical check-up if necessary, or possibly laboratory tests to exclude other possible causes for your condition. These are done to confirm that what you’re experiencing are not due to other medical conditions which may give rise to similar symptoms. Hence, if your psychiatrist asks for these procedures to be carried out, don’t feel too worried! Questionnaires to further assess your symptoms may also be given, so do make sure to answer them as truthfully as possible.
Depending on the complexities of your condition, medication options or other forms of treatment may be prescribed. If you are given medications, the psychiatrist would counsel you on how you can tell if the medications are working. Over the course of your recovery journey, take note of how subtle changes to the medications made by your psychiatrist affects you. Do they stabilise or improve your condition, or do they seem to send you on a downward spiral? How have you been feeling since you started taking them? Whatever the outcome, keep your psychiatrist in the know of how you’re coping. In the same vein, it is very important that you do not adjust your medications on your own without seeking professional advice! Patients may get impatient if they’re not seeing the desired change after a while, but constant and unregulated changes can cause undesirable fluctuations, potentially worsening the situation. We need to understand that there could be catastrophic, life-threatening consequences if we do not take them seriously.
In general, psychiatrists usually work closely with psychologists and therapists, as some mental health conditions are best treated with both neuropharmacological support and psychotherapy. Thus, your psychiatrist may also refer you for psychotherapy if deemed fit. Depending on the level of care required to address the patient’s symptoms, psychiatrists may recommend treatment programmes if more intensive care is needed.
Motivational Interviewing (MI) is a widely used evidence-based technique to encourage behaviour change. According to clinical psychologists William R. Miller and Stephen Rollnick, “MI is a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.” In the clinical setting, it has been proven effective in tackling certain issues such as smoking, substance abuse, or other compulsive behaviour disorders including problem gambling, hypersexuality, or compulsive spending. In a way, MI serves as a decision aid and to guide clients towards making the necessary lifestyle changes. It assists clients in weighing the pros and cons of their respective situations, and encourages them to assess the benefits they can reap if they were to change their behaviour.
MI works best for individuals who fall within any one of these categories below. Of course, this is not to suggest that MI doesn’t work for conversations and discussions outside of these categories.
High ambivalence: These people are still experiencing mixed feelings about their situation. They sit on the fence, contemplating if they should make any changes.
Low confidence: These individuals are doubtful of their abilities to make the necessary lifestyle changes in order to overcome difficulties.
Low desire: These people are uncertain as to whether they really want to make a change.
Low importance: The line between the costs of the current situation and benefits of change is blurred, leaving the situation unclear.
In general, there are 4 fundamental processes to MI:
As with all other therapeutic methods, establishing a solid and productive therapist-client relationship is extremely important. This involves asking open-ended questions, affirming clients’ strengths, reflecting to clients what they may wish to express but have not yet spoken aloud and summarizing what has occurred in the therapeutic interaction. Having respect for the client’s autonomy is also a key aspect.
At the beginning, not all clients will have a clear goal in mind, and may lack direction and insight. This process gives the interviewer and the client the opportunity to narrow down on a shared goal or purpose that they can work towards. With that, the clinician is better able to steer the client into a directional conversation about change.
Essentially, the interviewer needs to be able to pick up on hints or cues which may suggest the client’s willingness to change. Oftentimes, clients may express their desire to change and their fear of the potential consequences if they do not. Interviewers will then employ more open-ended questions to guide the client, giving him a chance to elaborate on his attitudes, thoughts and motivations. Normalising ambivalence and ensuring that sensitive information is explored without judgement is also important.
Planning should come from the clients themselves based on their insights, self-knowledge, values and motivation. Typically, interviewers do not attempt to take full control and to force a commitment plan onto the client. Doing so will not only disempower the client, but also strips the client of his autonomy. However, they can step in when clients are stuck or unsure as to what they can do to make the necessary changes, as long as their advice is wanted.
In a MI, a decisional matrix is often used. This involves an open discussion of the situation at hand, allowing the client to assess the costs and benefits involved. What are the benefits of staying the same, versus the benefits that come with change? What costs are involved if they chose to stay where they are, than if they made changes? MI isn’t about having psychologists force their views on the client and having them follow their orders. By having an open discussion in a safe, non-judgemental space, clients are able to reflect on their behaviour and come to a decision based on a “fair” hearing. By getting clients to think about the costs of staying the same, this also allows for greater cognitive dissonance, making changes more likely.
Another common aspect of MI involves the Columbo approach, which can be characterised as deploying discrepancies. This technique was inspired by 1970s television series Columbo, in which TV detective Columbo would apply it to rationalise discrepancies and to seek additional supporting information. When contradictory information surfaces, the interviewer will then present a question in a way that makes the client reflect on their mindset. For example, a question could be phrased as, “How does your (risky behaviour) fit in with your goals?”
Motivational interviewing is sometimes used on its own or may be combined with other treatment approaches. In short, MI is a method of communication rather than an intervention, and it serves to help you attain greater confidence in self-improvement and to make crucial behavioural changes for the better. MI doesn’t force you to commit to a plan, nor involve scare tactics to pressure you into making decisions that you feel uncomfortable with. It does, however, motivate you and aims to help you achieve greater clarity on the importance of making a change. If you or a loved one needs to seek professional mental health support, do reach out to our team!
I made an analysis of the 10 Rules of Marriage that I found on the internet recently and received several requests for proactive and positive rules that couples can abide by.
Based on what I understand and practise as a relationship expert, I came up withWinifred’s10 “rules” that I hope will encourage you to invest in your marriage or relationship.These rules are derived from the principles used in Gottman Method Couples Therapy as well as Applied Positive Psychology that I am skilled in.
While I call them “rules”, they are not cast in stone. Pick and decide with your partner on the rules that are most relevant to your current stage of relationship. Let’s dive in and look at each of them.
Be a safe harbour to each other
What this means is that you will be the person that your partner will turn to for connection, support, comfort and love. There is intimacy and closeness when you can be your real and authentic self. You also prioritise each other when you make decisions. For this safe harbour to be strong, you make effort to safeguard the relationship by setting clear boundaries on rules of engagement with the opposite sex. You don’t take the marriage for granted. For couples who share the same faith, pray and grow your faith together.
Adopt a growth mindset
Be willing to learn and change, recognising that there are skills that each of you can learn in order to deepen your relationship and connection. Instead of seeing your partner from your own perspective andforming your own conclusions, entertain the possibility of discovering new things about each other. Continue to work on being the best version of yourself for each other. Cultivate self-awareness so that you can continue to reveal your true self to your partner.
Listen, summarise and validate
The first rule in listening to each other is that you’re not both talking at the same time! Unfortunately, I observe thecontrary a lot in my couples. After a while, both persons are talking at the same time and no one is listening. Alwaystake turns to speak. To ensure that you are truly listening, make sure that you are able to summarise and validate the point or position of your partner to his/her satisfaction. Always check to see if you’ve heard each other’s side of the story correctly. This is the foundation of good communication.
Much research has shown the importance of gratitude not only in the formation of a new relationship but also in the successful maintenance of these intimate bonds. Additionally, the experience of gratitude enables you to feel closer to your partner thereby leading to a greater satisfaction in the relationship. When you are grateful for your relationship, you’re less likely to compare yourself or your partner with someone else. Learn to focus on what is good in your partner and the relationship will become stronger and deeper. Verbalise your gratitude to your partner frequently to minimise the feeling of being underappreciated.
Do small things often
It is more important to show your care and love through tangible actions frequently rather than doing a grand gesture once or twice a year on special occasions.You strengthen the emotional connection between the two of you when you do small acts of service and love to your partner by sending a message to encourage him or her on a challenging day or to share in the joy of small wins. Identify your partner’s love language and show your love accordingly in a way that he or she can receive and appreciate.Thank each other regularly, affirm the virtues you admire in one another and be willing to apologise first to repair any regrettable incidence.
Build a healthy love bank
A “love bank” is a collection of what makes you feel connected, cared for and valued by your partner. The concept is similar to a normal bank account where there are deposits and withdrawals. When you build more positive interactions with your partner, your emotional love bank account flourishes. You feel safe and secure. Even if you have a “withdrawal” (for example, a small argument), it doesn’t feel too threatening. You know that you have sufficient amount in that will not result in a deficit. When you notice that your partner or you are getting more annoyed and easily triggered,there is a danger that you may need an overdraft. For example, things that don’t usually bother you about your partner’s behaviour, irritate you now. Pay attention to it and put in effort to increase the emotional connection. Ways to increase your love bank include understanding your partner’s inner world, showing fondness and admiration, and turning towards his or her bids for connection. Repeat #3, #4 and #5. Be mindful not to turn this into a game of reciprocity where comparisons are made on who’s done more.
Approach conflict with curiosity
The ability to regulate conflicts is critical to the success of a relationship.When you address your differences adequately, they are less likely to snowball into a massive conflict. When you find yourself in a different position from that of your partner, be curious and ask questions about his or her position so that you can deepen your understanding of your partner. What happens more often than not is an assumption is made that your partner is making your life difficult bybeing oppositional or disagreeable. This perception is detrimental as you begin to assume the worst in each other. Those who are conflict-avoidant often find it challenging to regulate their own emotions and the emotions of their partner during conflicts. It’s important for them to learn the skill to call for a break so that they can self-soothe before continuing with the emotionally-charged conversation. When you are curious and re-frame your conflict as an opportunity to deepen your understanding of each other, the differences become less daunting.
Be playful and laugh a lot
Recall the time when you first got together: there were easy conversations, plenty of laughter and fun. As you progress to different stages of the relationship, responsibilities and burdens will increase. As such, it is easy to slip into a routine and forget about having fun together. Cultivate and utilise your sense of humour as it is a good way to connect with your partner and to lift the mood when the going gets tough. Watch comedies, share jokes and funny stories so that you can laugh together. If you have kids, laugh with them too. Life is hard and it will be harder when we take everything too seriously.
Support each other’s dreams
Couples who decide to be committed and marry each other usually have dreams in mind. When you are not intentional in having such an important conversation with your partnerabout their dreams, it is easy to be consumed by day-to-day tasks and activities that you forget the big picture. Take time to find outand revisit your partner’s dreams regularly. Initiate such conversations when you’d like to take a new direction in your life. You can enhance your relationship by creating shared meaning and dreams. Common ones include building a family and home together, finding a cause that’s meaningful for you to support, creating impact through the work that you do either professionally or in the community you serve. Discussion of such dreams is important as it will affect the decisions that you make as a couple and family.
Accept influence and compromise
It is impossible to always find agreement between two individuals. Therefore being able to accept influence and compromise is key to the success of the relationship.Accepting influence is about developing your ability to find a point of agreement in your partner’s position. It is not about insisting that you’re right or finding evidence that your partner is wrongall the time. In accepting influence, it doesn’t mean that you need to change into someone you are not. You need to have a good sense of who you are at your core, and be sure to protect it so that you are not coerced into becoming someone else. If you make the decision to be the person that your partner needs you to be, accept your responsibility for that decision rather than blaming it on your partner. The challenge in accepting influence is really about relinquishing your control and preferences some of the time to prioritise the needs of your partner.
I’d really love to hear what you think of these “rules” and which might be the ones that you will focus on cultivating and practicing. Feel free to email me your thoughts and questions.
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