Saturday, February 18, 2012

Treatment plan - part 3

The treatment plan with micro and macro counselling.

As I said in the previous post one can counsel at the micro or macro levels. As an example consider the hysteric personality type. This individual who is most often female has a basic problem with feelings and thinking. The feelings are overly strong and she needs to have more considered feelings. Also often when she feels she will stop thinking so at times she has to learn how to think and feel at the same time.

In addition she often has an overly romantic perception of her relationship with father. I wont use the word sexualized because people add in all sorts of things when you say that, but the girl has feelings for father that can be of a romantic nature. This may or may not be fostered by others in the family by commenting on the relationship between father and daughter. If this does exist, typically the woman will have trouble in adulthood with her males partners as she will see that these men never measure up to the ‘perfect’ relationship she has with father. She has never significantly detached from father which also disrupts her current relationship with men. She is fixated at the phallic stage of development.

Tattoo woman 2

Her sexual relationships with men tend to be all or nothing. In the beginning of the relationship she may be highly sexual and then at some point becomes completely asexual and looses all interest in sex. The switch may come when in her mind she realizes that the man does not meet the high standards that father set for a (romantic) relationship.

Upon enquiry one can begin to ascertain if some of these features form the core personality structures I mentioned in the previous post. For example one could enquire about her history of relationships with men and get her to talk about her relationship with father. How does she perceive him and so forth. If these seem to be a very dominant and pervasive aspect of her then it may be one of the core personality structures.

Alternatively if her strong and dramatic feelings and the inability to think and feel at the same time are also pervasive and quite resistant to change then they may also form core personality structures. One has now established part of the long term treatment plan for her.

Letting go

If one ascertains these to be the case then one can see how macro counselling can take place. As I said before counselling at the macro level involves not what you do with the client but how you do it. For example a client may present with the complaint of insomnia. After some discussion it is ascertained that the person has injunctions like Don’t get your needs met and Don’t be a child and these are related to the insomnia.

One needs to address these injunctions in order to relieve some of the symptoms of insomnia. With the non hysteric person that can involve redecision work that may involve some significant feelings and regression by the client. With the hysteric client one does not do this so much. One changes how they work at the macro level. Therapy with the hysteric client is more cognitive and involves much less feeling work. Yes the therapist may encourage the hysteric client to experience and express emotions but will always be corralling the client to only have considered emotions. At times the hysteric client may even complain that therapy is boring because they are missing the excitement of having intense emotions.

The overall treatment plan with the hysteric client is to only have considered emotions and to do a much more cognitive type of work. When working with a paranoid or schizoid client this is not required in their treatment plan. So what one does with the paranoid and hysteric client is the same but how you go about it is different because the macro level are different. The overall treatment plan is different. One works with the same injunctions but in a different way.

The paranoid client

Anyone who has studied the writings of Freud will know that hysteria and the hysteric client were very important in his formulations of the foundations of the theory of psychoanalysis. He discovered that working with hysteric clients seemed to work using his new theory of psychoanalysis. Psychoanalysis is a thinking style of therapy. It encourages the client to think about who they are and why they are. There is very little emphasis on intense emotional expressive work. At the macro level psychoanalysis works with the hysteric because it encourages them to think rather than to feel.

The point at hand is to describe how the macro approach or the treatment plan can be defined. In other circumstances what may begin as micro counselling eventually turns into macro counselling. The other day I was working with a woman who would be of a schizoid personality type. It became apparent over time that her primal response to stress was flight. Of the three - fight, flight or freeze - when she was highly regressed she had a very strong drive to flight. It was seen that one of her primal personality structures was the mechanism of flight which she had used consistently throughout her life when placed under considerable stress.

Of course my next step was to suggest a No Run contract to her. This was a micro counselling technique, to remove her primal response of flight from her relationship with me and then to work through her reactions to that. She did that and we discussed the various psychological ramifications of that for her. However the No Run contract still remains. I will raise it from time to time but it sits there ever present in the background.

Dont look
The schizoid client

She is now involved in a therapeutic relationship with me where one of her core personality structures - the mechanism of flight - has been nullified. It can no longer be used by her and this persists day after day in her relationship with me. This can be seen to be therapy at the macro level as it directly addresses her core personality structures. It is part of the overall treatment plan for her, to let go of the mechanism of flight as a problem solving technique.

Thus we have an example of a specific micro counselling technique evolving into part of the macro counselling approach or part of her overall treatment plan.



  1. I don't know why you are calling it a no run contract. Really it is a trust contract? If you break her trust then why wouldn't she cut her loses and leave? A trust contract is a different kettle of fish. Also if she agrees a no run contract then you could take the mickey?

  2. I wasn't being sharp in my comment when I said you could take the mickey. I wasn't meaning you as in you, rather you meaning joe blogs therapist. Thought I had better clarify, though I think you know me by now anyway.

  3. You are right Kahless there is a sub clause to the no run contract.

    I will not run and the therapist agrees to operate in their usual way of I’m OK, You’re OK. So no mickeys, being trustworthy and so forth.

    And yes the client is trusting that this will be so, that the therapist will keep his part of the deal. If you have an untrustworthy therapist then the basic treatment contract is null and void anyway.



  4. The 'no run' contract sounds like a good one to make with a presentation of schitzoid where the real trust is built up over a long period of time. An 'intro' to trust; a bite size chunk that doesn't bump into too many defences, and a way of working on two contracting levels (the social and psychological) at the same time. How far into the therapeutic relationship did you made the contract? Did you bring it in the room as a sabotage strategy explicitly? Loving your personality/pillar model by the way :) Thanks for awakening some of my brain cells too :)

  5. Hello,
    I usually say the persons name or at least their cyberspace name when I say hello but I am not too sure what to call you. It could be LIAAG but that does not seem right.

    For the person who uses flight as a basic coping mechanism such as the schizoid can i may introduce the idea of a no run contract quite early on, but it depends on how they do their flight. Some schizoids can 'flight' with physical relocation and hence the no run contract can be quite useful. Others don't have to move anywhere and will simply 'flight' in their mind and feel miles away when they are sitting in the same room as me. Of course a no run contract is not applicable here. It is possible to have a psychological no run contract but that is harder to do.


  6. Ah yes of course, that makes perfect sense (the psychological 'no run'). Thanks for your reply. My name is Dena by the way (a real name rather than a cyberspace one).

  7. Hello Dena,

    yes the no run contract is quite useful at times