Is It Okay For You And Your Friend To See The Same Therapist? What About Partners, Exes, Cousins And So On? Talking About Confidentiality And Neutrality

Is it okay for you and your friend to see the same therapist? What about partners, exes, cousins and so on? This has come up a few times recently and it’s a great question. 

 

There isn’t a standard answer because there are no rules. 

 

You may think that there can be no overlap but that isn't possible. We live and work in the community.

 

Mental health practitioners who work in companies see people who work together and who live in their neighbourhood, just like those who work in a local hospital, so it's a very common situation.

 

Mental health practitioners can see members of the same family, people who work together, sleep together, who know each other on social media etc etc. 

 

What’s key is 1) confidentiality and 2) neutrality. 

 

Confidentiality. Some therapists share their notes in their office with colleagues or staff. I work alone and I prefer to maintain strict confidentiality. 

 

If you see me, I talk to you and to you only. Between sessions, I forget I know you. 

 

If your best friend, cousin, work colleague, or neighbour also sees me, I act as if I don’t know you in therapy sessions. In fact, I won’t even confirm or deny that you’re my client if anyone asks. 

 

So, I won’t talk but if you and your friend want to discuss your sessions, that’s your decision. You know what works for you.

 

Neutrality. The therapist helps the client reach their goals. That’s the job in a nutshell. In the session, it’s all about you. 

 

But with cross connections, I often hear the same story from different perspectives. Like if there’s a product launch, I may hear about the event management side from one client and from the product side from another. 

 

Confidentiality means that I can’t let information I hear in one session bleed over into another.

What’s said in a session, stays in that session.

 

This can be tricky when secrets are involved. 

 

For example, client X owns a restaurant chain and client Y works as a chef. Client X tells me that the chain will be firing 10% of all staff. In another session, client Y hopes for a big bonus and plans a long holiday. 

 

Confidentiality means I can’t talk out of session. So when client Y is talking away about holidays, I have to shut off and not warn them the company is actually in trouble. Which is awesome confidentiality but poor client Y, right? 

 

When it comes to dating, divorce and so on, secrets and confidentiality can really complicate matters.

 

So, I have this approach for taking on new clients:

If you know each other, that’s fine by me. Work colleagues, cousins, neighbours… it’s all fine.

If you think the relationship is very close and you’re thinking about neutrality or confidentiality, tell me and we talk it over. 

 

Generally speaking, if you are happy together and want help for two different things, like one wants to talk about anxiety and the other wants to talk about career happiness, I’m fine with that. 

 

If you’re close family or in a relationship and both of you want individual sessions to talk about your relationship, that may be tricky.

With two new clients, especially those living together, I usually suggest they see a family or couples therapist.

If one is an existing client and the one is new to me, I usually suggest the new one sees someone else. It’s just easier.

Should that not be an option (because you are in a place with few professionals, or you're LGBTQ in a country where that is illegal), we can discuss it. Depending on what’s going on, I may say yes or no. 

 

Of course, this is when all the info is out there and up front. 

 

Sometimes relationships aren’t clear at the beginning or they change. 

 

For example, I may not know for months that client A is the ex that client B is telling me about, or that client Q works in the same company as client P. Sometimes, client J is delighted with a new friend and I discover the new hottie is my client L.

 

Usually, it’s all good. Like accountants, lawyers, doctors, nurses and other professionals, I compartmentalize.

 

The one curiously tricky situation is when I discover that two clients who I thought of as single or independent are partners. 

 

If they tell me in session, we can talk it over. But if they don’t, and I don’t know if they know their partner is in therapy, I can’t ask without breaking confidentiality. But that’s a discussion for another day

Image by Pretty Sleepy Art from Pixabay

Expat Life: Staying Sane During Visa Application And Renewal

Digital nomading sounds so glam. Working on your laptop by a sunny pool, in December, freshly squeezed guava juice at your side. What could be nicer?

While it's lovely to travel, working abroad also means endless paperwork for visas. I'm doing ours at the moment, and so it's at the top of my mind.

Here are some thoughts on how to stay sane during this challenging time.

Stress #1 Control, Agency and Importance
The visa directs where you live and for how long, so it's important. 

You have very little control over when or whether it's granted. As human beings don't do well with helplessness, this will be a primary stressor.

Mental Health Tip: Acknowledge that feeling stressed because you are helpless and uncertain is actually a sensible reaction. Breathe through it. Practice self-care.

Practical: You're doing this for a reason, so treat it like a project and set goals for success and failure. Do you want the visa because it looks good on the CV? Because of the income you make? Some other reason?

Whatever it is, put a value on it and figure out how much effort you are willing to spend to get it. Then make a failure target so that you know when to walk away.

For example, "Getting the visa means an international credit on my CV and will net me $1500 a month more in income for two years. I'm willing to invest one month and $5000. If there's no positive by date X or they ask for more money, I walk."

Stress #2 Backup plan
There are usually options, so make a list of alternative destinations and jobs. Maybe you stay home, go home, or try another country.

Most importantly, make sure you work out a timeline! You don't want to be stuck in one country with paperwork that's running out, or having trouble with the revenue stream, on top of being unsure of where you're going.

Stress #3 Confusion and Conflict
Visa bureaucracy typically involves several government departments, all of whom have different agendas. They likely don't talk to each other. If you've applying for a new visa, you may spend all your time dealing with people who are as new to this as you are.

Mental Health Tip: Acknowledge that feeling stressed because you are helpless and uncertain is actually a sensible reaction. Breathe through it.

Mental Health Tip: remember why you're doing this! See the stress as partial payment for what you're going to get out of it when you succeed.

Stress #4 Time Budget
Be certain you have a time budget set aside. As it typically takes several dozen hours of labour of which collecting documents is the simplest part, treat this like a major project with milestones.

Practical: devoting a block of time regularly can be more useful than jumping to respond. Me, I do my paperwork in a one morning block, and devote a whole day to visiting a department. If I finish early, I treat myself to time off and pat myself on the back.

Stress #5: Follow The Basics
Eat properly, get decent sleep, eliminate small stresses and exercise. Yes, obvious, but without veggy, protein and sleep your body can't work. So be certain you don't sabotage your health.

Mental Health Tip: I get off social media and reread favourite books. The lack of notifications lower my overall alert level and the old favourites are a throwback to old comfortable times.  Try it and see!

Stress #6: Rope in Friends
A problem shared is a problem halved, but apart from the emotional support, talking to a local friend will help remind you why you like to stay.

If you're looking for tips, chat to someone from your own country who recently and successfully managed the process. If you're lucky, there may be a shortcut or two you didn't know about.  

Mental Health Tip: remember the points of stress #1 Control, Agency and Importance

I speak from the heart. This is my fifth country, and I'm in the middle of applying for my fifteenth? Eighteenth? Gazzilionth visa. I used to work visas for expat engineers in other countries too, so all in all, I've processed more than a hundred visas over 30 years.

The biggest takeaway is that I've learned that all countries are hostile to expats. You can have politicians moaning they need workers, or raving about luring you in with special promotional paperwork, but it's not them doing the actual visa processing.  

So try not to talk it personally. Decide if it's for you, and if it is, go do it.   

Finally, if you need mental health support, book a session with me. I'm nice and affordable as I live in a developing nation. And I'll know what you're talking about.

Do You Qualify For A Discount? And Are Discounts Racist? Talking About Mental Health Costs And Discounting Frameworks

 

Remember how last October I decided not to increase my rates? Well, it seems to be causing some confusion. It also caused a fight, and therefore I'm doing some thinking.

Let me explain, and tell me what you think.

In my therapy work, I am based at home and online, so I pass on these savings to clients. As I'm in Malaysia where living is cheaper than in Europe, I'm very affordable, charging just US$35 per session.  

In addition, I offer a discount rate to clients in Malaysia. Why? Because Malaysia is a developing nation, and a lot of the people, especially young people, are quite poor.

As I've said before, I'm okay with working a little harder in order to give the people in my community a little bit of a break.

So I charge a local rate of RM110. (correct in Nov 2022)

From time to time I've had people living in first world nations asking for discounts and saying they can get third parties to pay the local rate.  The answer is no.

I'm willing to work a little harder to help my community, but there's a limit. Even my top rate, US$35, makes me significantly cheaper than my peers. 

I also need to earn my living, pay back for the 7 years tuition that is needed to enter work as a therapist, and prepare to look after myself in old age when I can no longer work. 

Some four or five years ago, before I had two separate rates, clients picked the payment method that worked for them. But my pricing structure has changed, so that no longer applies. I now have a two-tier system.

It is also true that some of my younger local clients who started with me while in college in Malaysia and then moved abroad kept the low rate. I closed one eye and let them stay on this as a courtesy because emigration is expensive and mentally challenging. 

And yes, I've also let a few families overseas in trouble in cheap.

Most people are okay with this. However, others misunderstand or resent this flexibility. I got some very nasty responses from one individual recently.

Hence the thinking.

Discounting is always controversial because it's natural to love a discount and to feel bad when you don't get one. Even so, charging different rates is common in mental health practice, mainly because so many can't afford the service but need it.

Typically, practitioners use means testing, where they offer a discount depending on your income. Mostly, they ask to see wage slips. 

I refuse to do this for several reasons. 

I find it intrusive. I don't need to know what you make, and I certainly don't want to get into how you spend your money. For all I know, you're making peanuts and have a rich relative who pays your bills. Or you earn a bomb, and are keeping your huge family. It's none of my business.

Also, as many people link income and personal worth, it may hurt or worry to discuss this topic. I won't do that to my clients. 

As for asking to see wages slips - OMG, that says you don't even trust people to be honest! I'm so not going there. I actually make a point of invoicing after the session, to show I trust my clients.  

I don't say means testing is wrong. But given the issues, it's not for me.

So, is my system of discounting based on geographical location racist? 

It's not racist because I don't ask people about race, but it's probably something 'ist'. Locationist, maybe? My thinking is based on local salaries and local purchasing power. I think that's practical, and although it's not foolproof or ideal, it's the best I can come up with. 

No, I don't want to apply special rates to various countries based on average income. I'm happy to help my community but I'm not a saint. I am running a business, not an NGO. Also, practically speaking, I'm not going to research other economies every time I get a client from a country that's new to me, either.

So there you go. That's my thinking. If I'm wrong, tell me how and why, and I will reconsider.

As for now, I love what I do, but I don't want to fight about money. So here are my rules, clearly and concisely.  

If you're living in Malaysia, you get the local rate. If you're not, you don't. No exceptions.

I'm putting my foot down, establishing my boundaries 😊

Will I adjust my rates for the clients abroad who get a low rate out of courtesy? 

I'm in several minds about this. 

Part of me says that they should not be affected because I'm annoyed by the rantings of some entitled twit. 

But another part of me says that really, if they're now established in first world countries, they should move to the other structure. Maybe I'm a bit too soft there?

I won't make a hasty decision. I'm going to sleep on it. And if you have an opinion, please do share. I'd like the insight.

Update: when people migrate, I'm taking it case by case. As there are no universal moral rules, I'm not going to break my head trying to make them. 25th November 2022

Shock, Trauma, PTSD - The Basics Without A Lot Of Technical Waffle

 

Malaysia is a very safe country to live in. We have no wars, no terrorist attacks, and no riots. This is terrific but as a client pointed out last week, it also means that many of us don't really understand how shock/trauma/PTSD works. So I am writing this piece at their request, in the hope that it helps promote understanding.

Story One: Kim

When Kim was small, his mother would beat him every time she didn't score an A at school. His mum would make him wait while she got the rotan.

Today Kim is a grown man with a job in HR. Her colleagues like him, he has lots of friends, but Kim has a secret.

He jokes that he has shares in Foodpanda because he never cooks. Secretly, he doesn’t cook because when he enters a kitchen, his breath catches in his throat, his palms sweat, and he feels sick. 

Story Two: Nora

Nora is a police officer. Three months ago, she was part of a team that investigated a missing man. The family claimed he'd gone off for an outstation job, but the neighbours reported a lot of fights.

Her team was suspicious, so they looked into it. They found the man's body hidden in a patch of rough ground near his family home.

Nora was physically sick when she first saw the body. Then she was okay again.

During the rest of the investigation, the family confessed that they'd beaten and tortured the victim. Nora wrote up her reports, consulted with the prosecutor, and moved on to the next case.

But somehow, this incident has stuck with her. Three months later, she still has bad dreams. She feels disconnected from her family. Sometimes, she catches herself looking at her cousins and wondering if they are secretly judging her.

Also, she can no longer enjoy her favourite Netflix cop show. Whenever on screen they go into an interrogation room, she remembers how normal that family looked as they told her how they'd killed their son.  

What do Kim and Nora say?

Both Kim and Nora worry that they're going crazy. Kim can't figure out what his beef is with kitchens. He thinks he might have kitchen phobia, or a cooking phobia. Nora thinks that police work is tough and maybe she just isn't cut out to be a cop. Both are embarrassed, and so they don't tell anyone about their secret.

What's really going on?

Kim and Nora suffer from shock or trauma. 

Kim suffered from repeated trauma when he was small. His mum often made him wait in the kitchen, and little Kim learned to associate the stove with being beaten. He forgot exactly how it all hung together because more than ten years have gone by, but the body remembers. When Kim sees a stove, his mind goes straight back to the trauma of being beaten.

Nora witnessed a tragedy, a family who actually killed a loved one. Seeing the body and hearing the story over and over again from the family, and writing the report, and discussing it with her colleagues, has traumatised her.

In her shock, Nora wonders if the whole world is secretly nasty and dangerous. And every time she sees something that triggers her memory, like an interview room on TV, she's reminded of the past and traumatised all over again. 

Shock, Trauma, and Posttraumatic Stress Disorder (PTSD)

Experts argue over distinctions and exact definitions are different in various countries. You can get into that if you like it's not necessary for grasping the basics.

What you should know is this. Shock or trauma is upsetting. If you are frightened, angry or scared when it happens, that's a healthy reaction. If someone beats you, or you see a crime, you should have emotions!

In a lot of cases, time will heal. Many of us cry, have a few bad nights, and then the emotions fade and vanish.

But for others, these thoughts and feelings stick around. Sometimes they last for years. Sometimes they actually get worse over time.

What it is not

It's not because people are weak, silly, or being dramatic.

Saying that is victim blaming which is mean.

Note: for the Kims in this world, they are often told, "Oh well, everyone is beaten and they're okay with it." No, they're not. Violence is never healthy.

Why exactly does it happen?

That depends on the model you follow. Me, I think it's not one-size-fits-all. There are several models that work well, but none are universal. Again, I don't think it's important outside of the profession.

Give me a list of possible trauma events

Childhood physical abuse and violence

Being the target of sexual violence

Being the target of a crime

Witnessing a crime

Being in or witnessing a war or terrorist attack

Physical assault

Being in or witnessing an accident

Being threatened with a weapon

 

When should we look for help?

If you've had a recent shock, talk it through and be kind to yourself. If you're having flashbacks, trouble sleeping, crying jags, or overwhelming feelings after a month, have a chat with a mental health professional. If it's been more than three months, definitely go.

Note: when you do see one of us, we'll help you figure out if it's anxiety, shock, depression, PTSD or a combination, okay? So don't worry.

How do we fix it?

First, we talk it through and figure out how your experiences affect you today. Then we figure out triggers and we help you learn new thinking and behaviour. Useful approaches include cognitive behavioural therapy and exposure therapy. <- you can google these

We do this very gently and we avoid reliving the experience. In the past, people thought bringing emotions to the surface was healing. Now we know that it can be as traumatising as the original experience. So we are very, very careful.  

Note: as a client, you have total power to say stop, to call for a pause, and to put in boundaries. In fact, it's part of the process.

My friend has trauma/shock/PTSD, what do I do?

On TV it's all about hugging and being there but frankly, everyone has different needs.

So my best advice is that you wait until you two are talking quietly together, and you ask, "What do you want me to do?" Then listen.

I hope this helps. If you need to talk to a mental health pro, PM me.