Friday, May 13, 2022

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 RM100.

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? 

Honestly, 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.

Tuesday, May 10, 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.




Thursday, April 28, 2022

Thinking of being self-employed? Some thoughts from a self-employed counselling psychologist...

A photo of Target, because he's handsome

I've been self-employed for over 25 years now but there's one thing that still gets to me: an unplanned free day. 

Crazy, right? Year in and year out I've made my business targets, fed myself, housed myself, and made enough to put money aside. Success by any standard. 

But show me a day with no deadlines or planned income and my radar goes off. If there are two days, I'm nervy.  Three days, and I'm deep in backup plans. 

Last time I had three unplanned free days was about 10 years ago. That's when I was still freelancing as a writer or content provider as people call it now. 

I was sitting by the pool on a Wednesday, a happy luxury benefit of being your own boss, and there was no work for the rest of the week. So, I did some cold calling. 

Usually, I plan on one in ten returns, so I called five new companies and pitched, expecting five fails and having to hit another five. Much to my surprise, three of them hit, and I didn't see the pool again for months :-)

Back in 2013, I saw the writing on the wall for content writing, and put myself through school to add a Masters in Counselling to the Degree in Psychology. I reckoned a portable job in that market would suit me, and took the risk. 

I put a year's writing profit into the education, and gave up some of my time for two years as well. In total, I reckon I paid some RM50,000 in direct fees and lost writing income to get that education and new career set up.

Overall, it was the right move. I have a sustainable business that's portable, and I love what I do. I'm still writing on the side as well. 

Today I have an unexpected day off. I had one last week too. I did consider worrying but decided against it. Now that I'm older and wiser, I'm watching Midsomer Murder, writing a chapter of the next Trigger Cullen novel, cooking a fancy schmancy dinner, and clearing out a drawer that's been bugging me. Because I've had several months of having way too much work, and I expect that in a week or so, I'll be pressed again.

Why am I telling you all this? Because the economy is tanking worldwide, because salaries are insanely low and so many people are thinking that it's better to go it alone.

I love being self employed but it's not for everyone. Here's three tips I think make the difference between make and break.

#1 Know what you do. As a therapist, I make complicated things simple. I'll work with you to figure out what's going on, and to lay out options. I'm also incredibly secretive, so you can talk and nobody will know what we talk about.

As a writer, I sell reliability. Once I say yes, you can leave me to do my job. Whatever it is I said I'd deliver will be on your desk. And probably early. 

#2 Be able to sell yourself.  If you can't tell people you're brilliant, and exactly why they need to hire you, you won't get business. 

#3 Be ruthless about money. You have to chase payments, or know how to weed out clients who don't pay. Otherwise you get work but no income.

If you're thinking of going it alone, I hope this helps. 

And if you want tips from friends who are also self-employed, check out the FB post and add your own tip too

Thursday, April 14, 2022

How To Be Happy: Culture Filters How We Think About And Treat Depression And Anxiety


Tic Tac's happiness is a paper bag
Tic Tac's idea of happiness is a paper bag

Feeling dull and can’t get out of bed? Must be depression. Can’t sit still or stop talking? That’s anxiety. Ticking boxes makes it all seem so cut and dried, but did you know that culture influences how we experience mental health?


Mental health practitioners working in melting pot communities (like Malaysia!) talk among themselves about how different groups experience and treat mental health.


With the pandemic fuelling public interest, this is an excellent time to open up discussion. That way, we can all make more informed decisions.


I’m a counselling psychologist working online with private clients from Malaysia, Singapore, Hong Kong, Australia, the USA, and other countries. Since I opened my practice in 2016, I’ve worked with some 250 people over roughly 4500 hours.


Here are three insights from this work about depression and anxiety.


Losing your pleasure in food. When your friend tells you about a fantastic laksa stall and you’re normally a fan but are not champing at the bit to check it out, figure out why.


If just the thought of taking time out has you worried about work or chores, it may be a sign of stress, burnout, or anxiety.


Not having the energy to go, skipping meals because you’ve lost your appetite, or deciding for no reason that it probably isn’t that good anyway, can all be signs of low mood or depression.


At prayers or meditation, you focus on your faults. Reflection can be a powerful force for good mental health, but if you find you are skipping celebrating the little joys, and going to town with hypercritical self-analysis, you risk pushing yourself into a spiral of negativity.


Spiralling and catastrophising, imagining the worst possible outcomes in your imagination, are associated with anxiety and depression. This is why journaling, an excellent exercise for many, can backfire if you suffer from these issues.


A practical first step is to restrict yourself to prayers and meditation designed to uplift, while you figure out what’s going on.


You are constantly scolding or quarrelling. Irritation, annoyance, and anger are key emotions that give us insight into ourselves and our environment. Usually, we feel angry when we perceive injustice. If you’re queueing nicely and someone pushes in front, feeling irritation is perfectly healthy!


But constant anger is uncomfortable and a sign of trouble. As the body and mind work together, a simple first check is to make sure you are drinking enough water and eating properly. It’s amazing how ratty we can get on a hot day when we’ve skipped a cup of tea and a snack.


If it’s not that, consider that anger can also be a reaction to feeling powerless or hopeless. These feelings may arise from specific events in your life or be symptoms of depression and anxiety. Sometimes, it’s all of the above.


Therapy approaches are cultural too

In the world of mental health, medication is the province of psychiatrists, medical doctors who specialise in diagnosing and treating mental illness.


Everyone else, therapists, counsellors, and counselling psychologists like me, are not medical doctors. We specialise in talk therapy. We cannot prescribe medicine or sell you supplements. (Anyone who tells you that supplements are part of talk therapy is scamming you.)


When you see a psychiatrist and take a pill, the medication works the same no matter if you’re a Buddhist from Miri or a Christian from Penang.


But with talk therapy, it’s useful to build approaches with culturally appropriate elements.


My number one tip is based on the fact that Malaysia favours group culture. Therefore, connecting with your support group is valuable.  Working out which friends can help you with what, while maintaining privacy, is practical and effective.


As for anxiety, I'm a huge fan of the traditional cup of ginger tea.


Studies show that ginger has medicinal properties thanks to gingerol, its main bioactive component. While the jury is out on how much gingerol soothes nausea and promotes mood stabilising hormones, it’s simple, cheap and, for many Malaysians, associated with feel-good memories.    


If you have medical conditions, check with your doctor first. But otherwise, drop a slice of fresh ginger into your next cuppa. Alternatively, a half teaspoon of plain powdered shop-bought spice will work just as well. 

Put your feet up, embrace the moment, and be happy.