Let's create understanding and communicate it
Every now and then we get blessed by an opportunity to speak and air our views, but not like this.
It's an honour to be invited to do so to comment on our local sphere, by established organisations like the ISAP. We at @thepsychpractice, wish to extend our gratitude to Dr. Delphine Mascarene and Ms. Maureen Lyons for their generosity and ongoing favour for us all the way here in Singapore. Here are their questions and our responses.
You may also wish to download the original article published in the ISAP's March 2018 Newsletter to all members here.
What do you feel is the greatest challenge as a clinician?
This is such a big question and I can imagine there are many challenges that may take equal precedence in many situations. Nevertheless, I feel that therapist personal struggles may account for a great deal of challenge whilst working with others in an interpersonal space (this I mean, I’m referring to dealing with the inter-subjective space, transference and countertransference). These struggles may take the form of responding to clients/patients in insecure ways. This takes priority for me because having supervised therapists over the years, I’ve come to realise that the hardest part of working with others’ insecurities is that these conscious and unconscious dynamics are inevitably expressed in the therapy space - these may inherently activate our own personal insecurities. Regardless of whether you’re a junior therapist or an experienced hand, we can always be knocked off kilter. If we’re not aware of these challenges, it can and sometimes run the therapist into violating boundaries and bordering into the unethical, despite well intentions.
Could you describe your work environment in relation to the Singapore culture?
I’ve worked in a psychiatric hospital environment for over 11 years now, and despite our nation’s overall enriched view of mental health, the negative stigma and layman view of psychological health is still cloaked in mystery and little understanding. In 2007, the government pumped in money to fund public education via the Singapore Mental Health Blueprint, so since then, there has been a lot more outreach activities involved in helping the public understand mental illness.
Another issue that may be problematic in our system is our local insurance packages and healthcare system. We do not currently have insurances that fully cover mental health services, specifically psychological therapy, and we do not have a welfare system that provides entitlement to a certain number of sessions available to all to access public or private outpatient psychological services. Currently and to my knowledge, we only have some opportunity to make claims for inpatient treatment as part of one’s psychiatric treatment regime. This is to me a lapse in our system and in some way inhibits the work that we could bring to the larger public. So sometimes, there’s a view that only the wealthy can afford psychotherapy, let alone psychoanalytic therapy.
How does psychodynamic theory adapt to the culture in Singapore?
I think this is an interesting question, and could well be a good thesis idea. Singapore is a country that has accelerated into a 1st world country since the early days struggling for independence in 1965. Given our advancements, I see Singapore to be a culture that may be too ahead of its time. I didn’t live through those difficult years in the early days as I’m an 80’s infant, but at the time, life after the 2nd world war was depicted as traumatic and difficult, following the Japanese Occupation. Singapore had to live through strife and on survival mode, and many families had to endure hardship and emotional pain. Since then, there may be a move towards modernity a little too quickly. As a nation, it’s great to have such advancement, but as a people, I think we are still an inwardly conservative Asian culture, but outwardly liberal. We are a nation of highly educated people but also we are perceived by the world to be “stoic” and “unemotional” as described by the news fairly recently. To me, there’s a need to be able to traverse these lines and what is deemed to be appropriate and inappropriate across generations and negotiating various religious cultures, ethnic groups and beliefs in our multiracial society. We also have a government regime that retained power since our independence that has been viewed to be “totalitarian” and does not operate as a democratic society as it purports to be. This context brings to mind the relevance of psychodynamic theory to provide a way to understand splitting, manic defences and repression (to name a few). I believe there’s a larger and deeper impact to us as a people and as individuals growing up and living here in Singapore, with particular family of origin patterns, as well as traditionally held beliefs and inconsistent styles of caregiving. These may set up interesting contexts and dynamics that begin in the family. And as we know, these are propagated whether you’re more open or live in an insular fashion.
What gave you the idea of starting a blog?
I believe it was forged from a hunger for more psychological “activity” in our local sphere. As described earlier, we move too quickly as a society and perhaps we might benefit from slowing down a tad, and reflect on our outward behaviour and internal experience. I believe in freely sharing in information for the benefit of others, and bringing like-minded others together. This may be one of the only ways to communicate that there are others like me who care and would like to connect. Whether it is the student learning the bits and bobs about psychotherapy or someone who is living in emotional pain, the practice blog (PLog) is to spread the word of psychology and psychological understandings of issues experienced in our work, and in some way (though limited) to dispel some myths about mental health issues.
Could you talk about your study group?
Our study group is a very humble beginning toward developing a useful and safe space for helping individuals who are keen on the therapy to enhance their understanding of the work. We do this through co-learning together, by means of readings, discussions, peer consultations. It sounds really serious, but we’re made up of friends and colleagues in the scene who do this in an informal and relaxed fashion. Wine and food are normally involved, and we’re usually hosted at someone’s home. I thought it’d be useful somehow and that we could benefit from the group dynamics, whilst learning the material together. No one is an expert, but all contribute to the discussions and stimulating further conversation. This could only grow and nurture our psychoanalytic sensibilities as we cope with seeing particular clients. I would invite others to start their own private study group and communicate with us so that we could share material and grow our therapy capacities. (Learn more about Psychoanalytic Study Groups.)
What are your hopes and aspirations in terms of your career?
I think after spending years in public health, I do hope to create a space of my own in the future, and perhaps venture out into providing accessible mental health services to the wider public. I believe that there is value to exploring our own creative potential and sometimes it’s only possible to do so externally with other likeminded individuals who see things differently. Diversity may not be valued or found to be appealing in situations that tend to see things in black or white ways, and this may be a dynamic that is found in many organisations that are comfortable in their own traditional (and sometimes viewed to be insular) ways. Who knows? I have other loves like teaching and mentorship, as well as providing clinical supervision. I’ve spent my earlier formative years in providing training for teams and leaders, and may rekindle that love again in some form.
I am currently looking out for new and energetic opportunities with others who are similarly psyched to be of service to others. I’ve also just initiated a start to the development of an analytic association here in Singapore, which is nonprofit and aims to be able to provide a shared space for psychoanalytic practitioners hoping to learn more from each other. You can hear about us at http://psychoanalysis.sg - home to the Psychoanalytic Association of Singapore (PAS). We are also found on Facebook and Instagram. I believe in partnering up with associations like yours (ISAP) and others, that we could learn more about forming a meaningful and worthwhile space together. Others I’ve been in contact with include respectable psychoanalytic institutions in Israel and Western Australia.
Any inspirational thoughts or practical advice that could help a person make that move towards therapy?
For a person seeking therapy for themselves, I think we need to recognise that it’s a daunting task. For many it’s a “do or die” situation, but many others may not really know what we would like to achieve in therapy. We might need to ask ourselves, what would we like to get out of therapy, or bring it up with your therapist that you’re unsure and to discuss this with them. This may assist the person to establish some focus for their therapy work. However, once you’re in the therapy encounter to abandon your expectations if you can. Try to participate and be yourself. Go at it bit by bit, and remember that it’s a process. The therapy situation may be intense, and one may often put it off, but my advice is to stay the course. It can be very worthwhile and deep process, if you commit yourself to it. As someone who delivers and had received personal therapy as part of my own training, I cannot imagine not having gone through the process and experience it first hand, especially if you provide some form of therapy to others as a therapist.
In light of your case study which cites and demonstrates transference and counter transference, do you feel cognitive behavioural therapy is as efficient as psychodynamic therapy in helping a patient with deeply rooted problems?
In my view, it really depends on what is being treated, and how the individual would like to be treated. If you’d like to reduce the symptoms that are viewed to be part of the distress, and are okay with achieving that reduction in therapy, that may be sufficient for the person. Furthermore, not all patients would want to be treated in the analytic fashion because it can bring about too much anxiety and their issues may be too acute, at the moment for such an exploratory methodology. But if it’s helping the patient resolve deeply rooted problems, I would always suggest psychodynamic therapy because it focuses on many aspects of the persons’ life simultaneously, including taking into consideration one’s personality characteristics and unconscious mental life. CBT is only as efficient as what it focuses on, and I believe it can be very “efficient” because it does not take into consideration many things that psychodynamic therapy does. For instance, transference and countertransference does not matter to a CBT practitioner, even if there are hints of it in the course of therapy. Though I must say, I’ve met some CBT practitioners who practice in a person-centred manner, and appreciate the transference/countertransference process, and include this in their work in some limited way. We don’t want to be viewed as being better, but being inclusive to many aspects of therapy that are possibly part of the presenting issue to therapy. As to the efficiency debate, I personally think the efficiency of psychodynamic therapy is often minimised or overlooked as there is now current evidence as to the efficiency of say psychodynamic therapy for the treatment of depression (for instance). Not only does research show that psychodynamic therapy is just as effective as CBT in symptom reduction, it also has been shown to continue displaying therapeutic effects even at 12 months follow-up compared to CBT. Here’s an excerpt from an article we wrote about the recent evidence published in July 2017 (https://thepsychpractice.com/plog/2017/6/30/just-in):
As exciting as it sounds, new research posted on the Journal of Consulting and Clinical Psychology, a high impact clinical psychology research journal, shows strong evidence to support the efficaciousness of Psychodynamic Psychotherapy as an evidence-based intervention for Major Depression!
If you're familiar with the area, this research is brought to you from research giants Driessen and Cuijpers amongst others. Here's some excerpts.
"Noninferiority of psychodynamic therapy to CBT was shown for posttreatment and follow-up anxiety measures as well as for posttreatment pain and quality of life measures, but could not be consistently demonstrated for the other outcomes...
...This is the first study that shows that psychodynamic therapy can be at least as efficacious as CBT for depression on important aspects of patient functioning other than depressive symptom reduction. These findings extend the evidence-base of psychodynamic therapy for depression..."
For more on the evidence-base on psychodynamic therapy effectiveness, read this post by Harvard Medical School, and check out this other article we posted on Evidence-based, effective Psychodynamic Therapy!
There is clear evidence to show that psychodynamic therapy is more efficient at retaining therapy benefits and that to me, is “efficient” for the long-term.
Thanks for the opportunity to share these views.