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.



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.



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.


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.

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Developing a treatment plan - part 2

I have spent the last few days working with clients. In that time I have consciously listened to the thinking in my head that I do about clients. Thinking I would normally do but not really been aware of. I have been listening to the thinking I do about formulating a treatment plan.

In the previous post I talked about micro issues and macro issues. This of course leads to micro counselling approaches and macro counselling approaches. I have tried to conceptualize this diagrammatically as such.



This diagram shows that the personality rests on a few basic structures. As a young child develops it will establish a few core personality structures and this can be seen to form the basic character of the child. This of course will be a combination of the child’s natural temperament plus the early decisions it makes from the Little Professor ego state (A1 ego state).

The term treatment plan as used here is that plan which addresses the core personality structures of the client. This will identify the overall direction the client can go in therapy and this is shown as the macro counselling approach. Macro counselling addresses these core structures directly. Micro counselling does not focus on nor address the core structures, instead it will address the personality features which rest upon the basic core structures.

Micro counselling is the vast majority of activity that occurs in counselling. Macro counselling is not so much what therapist does and are not the techniques employed but it is how the therapist goes about what he does or the basic parameters the therapist imposes on the therapy.



As I said before I have listened to my thinking in the past few days as I developed an understanding of the core personality structures in the client and then how I go about devising the macro counselling approaches.

The first thing I noticed was there was not much of a plan to how I went about this. Instead my thinking was quite haphazard as I discovered the core structures. What ever the client happened to be talking about defined what I thought in my formulations. The ones I thought of are added to the list I started to construct in the previous post.

Personality types - I use these a lot.
Fixated developmental stage
Current developmental stage
Attachment style
Compulsion to either thinking, feeling or behaviour
Primal reaction of flight, fight or freeze.
Behaviour patterns that have been consistent through childhood, adolescence and adulthood.
Six basic temperament features formulated in the New York study
(I am sure there are more and I do not fully understand the nature of the list I am creating here)

Of particular interest is when a client becomes highly regressed in therapy. This is when one will see the core personality structures being displayed. The more regressed a client becomes the more they will resort to their primal ways of problem solving. If a client’s primal response to stress is flight one will see this expressed more openly when they are in a highly regressed state.



Below is a list of some of the core decisions of the personality types. Much more is involved in the personality types but this does provide some of the core structures one would find in the different personality types.

Paranoid - The world is hostile so don’t trust anyone and deal with people by being angry and attacking

Schizoid - The world is scary so withdraw from it (people) and don’t show any of your feelings

Schizotypal - The world is scary so withdraw from it (people) and don’t think clearly by being a bit crazy

Antisocial - You can’t trust anyone & life’s unfair so take advantage of people and do what you like

Borderline - Relationships & life are very unreliable so frantically do anything to keep people around

Histrionic - I must be the centre of attention so I will be dramatic, flirtatious and highly emotional

Narcissistic - I have always been told that I am very important and the best so I will behave and feel like that

Avoidant - Life is scary and rejecting so I will withdraw and feel worthless

Dependent - I can’t cope with life and am worthless so I will cling to others and do what they tell me

Obsessive/compulsive - I have to feel in control of life and myself so I will be orderly and perfectionistic



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Developing a treatment plan

(This post is definitely a work in progress)

I was talking with a supervisee two days ago about psychotherapy as one tends to do! Somehow the topic of treatment plans came up. A treatment plan is a plan that is formulated by the therapist which provides the therapist (and client) with the overall direction of therapy. It identifies the general direction the client needs to go.

When a client presents at a session usually they have some matter they wish to address. This can be seen as a micro issue. This is different to the treatment plan which is a much more global understanding of the client and their psychology. One deals with the micro issue presented by the client but it is seen to form only one part of the overall marco issue or the treatment plan. Whilst dealing with the micro issue the therapist does this in the context of the overall treatment plan. It’s like the therapist has the treatment plan always in the back of his mind and all discussions are done within the context of that plan.


Don't get lost in the micro issue




My supervisee then asked how one formulates such a plan and I was a bit flummoxed by the question. I did not have an answer and it seems I had never been asked that question before.

I presented a few responses as I thought on my feet at the time and have subsequently given it more deliberation. Again I find myself doing something in therapy that I did not know I was doing. I can not recall ever reading about such a thing. All I know is that in my early days as a psychotherapist in various training groups we always talked about treatment plans but I can not recall ever talking about their formulation, which seems a bit odd now. Maybe we did and I just cannot remember.

What I came up with was a short list of things which I consider when developing a treatment plan. I suspect this is by no means a complete list.

Client core issues versus secondary presenting issues - characterological structures of the personality.

Personality types - this relates to the core issues.

Fixated developmental stage

Current developmental stage




I will certainly muse on this some more as it is an important idea for therapists and I am intrigued by the fact that as a young therapist we used to often talk about treatment plans but one hears them not mentioned much at all these days.

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8th life position

That is a good question Kahless,

So what is the life position of the victim? Is it I--,U-?
I don't see it as I-,U+

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My response

I do make some comment on this in my article.


The reason why the bully is not - I’m OK, You’re not OK and is I’m Not OK but you’re worse - is because it is assumed it is not possible to see others as not OK and still see self as OK.

The normally developing child will automatically see others as OK. It is seen as the natural human condition. If a child suffers adverse parenting then it may decide that others are not OK but a soon as it does this it must see self at least partly as not ok as well because it has adopted an unnatural psychological state. Secondly the life position of I-U-- describes the clinical situation of this individual much better than I+U-. They are trying to make self feel OK by making others seem not OK in their eyes at least.



The I-U+ person has adopted the natural state in seeing others as OK so that can be seen as correct. They have only decided that self is Not OK and that does not have to reflect on their view of others.

They have no motive to see others as not OK.



The life position of I--U- would seem to imply that I view others as not OK and I cope with that by viewing myself as worse than them. Perhaps you have defined a new clinical condition Kahless and discovered the eighth life position.

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Victim response to the bully

Zbig asks about possible responses to bullying

The bottom line in the victim dealing with the bully really has nothing to do with the bully at all. People will become involved in relationships (of some duration and importance) that support their life position. People will use such relationships to reconfirm over and over what they decided about themselves and life in general as a child.

If they decided ‘I’m OK’, they will become involved in relationships which support that view of self. On the other hand if they decided ‘I’m not OK’, they will become involved in relationships which will reconfirm that for them over and over. If therapy can assist the person to see self as more OK then the relationship with the bully just wont happen. The two people wont fit in the relationship. Of course this is easier said than done



Many potential victims of bullying simply use the avoidance technique. I have heard numerous clients tell me over the years how they would spend many a school lunchtime break in the library and the like simply to avoid the bully. This can be easily done when the victim has the choice but at places like school or work or in the family it becomes much harder as the person is forced to be in a particular environment. However if they can reasonably easily avoid the bully then that seems to be a sensible approach at least to take in the interim.

My personal view is that in the final analysis it is necessary for the victim in some form to stand his/her ground against the bully. To behaviorally make the statement - ‘I’m OK and will not accept the abuse”. This however is a vexed point and there are some who would definitely disagree with it. They say it is incumbent on the ‘organization’ to protect the victims from bullies and furthermore may make the point that standing up to the bully directly only encourages more violence and conflict.

I am all in favor of schools and the like having bullying policies and organizational strategies which children can use to assist them in dealing with the bully. I think they are a very good idea. I would want any child of mine to tell me if they were being bullied and then I would take some kind of action to assist.



However it seems to me it is important for an individual in the final analysis to make a stand for them self. Having others assist is a great idea but at some point one must stand up for self as that breeds self respect and a belief in self. If one uses an organization to try and stop the bully often the bullying simply becomes more subtle and sooner or later there are going to be circumstances where there is not an organization there to assist.

As to the idea that pushing the bully back breeding more violence and conflict one needs to look at the degree. If a child is being beaten up that is not bullying, it is criminal assault and needs to be dealt with by the police. Bullying at school with males usually involves shoving, verbal abuse, maybe a few punches, taunts and so forth. I agree that ignoring it to see if it goes away is a good first strategy. If it does not go away then pushing back is needed. As I said before there will be those who disagree with me on this matter. I understand their argument but it does not ring true to me. When the bully realizes the person is not going to take the position of victim the trouble stops. It does not cause an escalation of violence.



I understand this is also very easy to say and can be very hard for a child or teenager to do if they feel intimidated, lack confidence and a belief in self. So it may not happen over night but I would see it as a potential goal to look toward.

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The bully victim dynamic.

I was recently asked by a journalist to make a comment on bullying which I have and have decided to include it here as well.

The bully victim dynamic is a particular relationship style. Two or more people relate in a particular way such that bullying can be seen to occur between these people. The relationship is primarily based on power. From a psychological point of view the central feature of the bully victim relationship is power.

The bully and victim are actually quite similar in their psychological makeup in this way. They are both people who have a pervasive sense of powerlessness. This is something that humans find quite repugnant - feeling powerless. Humans have a strong, even very strong need to feel powerful or have a sense that they have some power in their life. They will at times go to great lengths to regain a sense of power. This is a core psychological need in the human psyche - feeling powerful.





Some children are raised in such a way that they have a sense of feeling powerless or not having any power in their life. Both the bully and victim are the same here. As children they both felt powerless. However they differ in how they dealt with that sense of powerlessness as children. Some children learn they can find a sense of power if they make others look bad. They discover they can feel powerful by making someone else feel powerless. The child who discovers this way of coping is a bully in the making.


To explain the psychology of how this work on finds an answer in the theory of seven life positions - here.

The theory of four life positions has been shown to have significant theoretical inaccuracies and that seven life positions more accurately describes human psychology in this way. With the four life position theory the bully would be seen as adopting the position of I+, U- (I’m OK, You’re not OK). The seven life position theory describes the bully as I-, U-- (I’m not OK, but you’re worse). This acknowledges that the bully has a basic sense of not okness (powerlessness) and deals with it by making others feel less powerful than him. This then allows him to have (at least a temporarily) a sense of feeling powerful. The victim gets caught in the relationship because it supports their life position and a sense of feeling not ok about self. The relationship psychologically fits for both parties. It allows them to reconfirm what they have always known about self and life. It feels ‘right’ in this sense.



I used to see this when I worked in prison. It was called ‘stand over’. The ‘stand over man’ would bully and usually extort items from the victim. Prominent stand over men would often have a group of younger men who hung around with him. None of them liked the bully but would associate with him and flatter him for some other reason. It may be because they felt it was better to be a sycophant to the bully than to be a victim to him. Or some may associate with him to increase their reputation in the prison.

But no one likes a bully. One of the main problems for the bully is he has no friends, the bully does not know how to have a friendship relationship. In the psychological sense a friendship is a relationship where there is no big power difference between the two parties. The bully finds this a very difficult thing to do as he needs others to feel powerless such that he can feel powerful. This need to bully others rarely only stays with the few victims the bully knows but pervades into other relationships in his life such as at home or at work. Often the bully is also being bullied by some other person in his life.



As to the question of cyber bullying. This raises an interesting gender difference in bullying. Male bullies usually at some point will physically assault the victim in varying degrees. They may use psychological bullying and taunts but they also have a ‘need’ to express the bullying physically. With females this tends to be less so. Psychological abuse and bullying allows them to achieve that sense of “You are worse than me so I am powerful” more so than with the male. Males tend to also need physical bulling to achieve the same psychological result. In this sense one could say cyber bullying is a feminized way of bullying as physical assaults are not possible. Males can certainly engage in cyber bullying but they also need the face to face physical contact at some point as well.

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The assumption of change in therapy

There continues to be much coverage of suicide in the press where I live in relation to the well known woman who recently suicided. The focus has now moved onto why and what can be done so that such a thing does not happen again. There is talk about diagnoses, what drugs could be used, other treatments and so forth.

From what has been said about her it seems it could have been a case of chronic suicidality. As I say in my book there are three common suicidal timelines.
Acute suicidal crisis. The suicidal urges appear quickly and usually in reaction to an event such as marital breakdown or incarceration. Suicide watch is very useful here as the urges can disappear after a not too long a period of time.

Slow suicidal crisis. The suicidal urges develop over time but tend to be cyclical over months. They come and they go due to treatments or spontaneous remission.

Chronic suicidal crisis. The suicidal urges appear and stay. They do not remit or come and go. Treatments have little or no effect. Suicide watch is of little use here. The woman under discussion seems to be of this kind.



There is an underlying assumption in all the current discussion about her in the press - that a solution exists to her suicidality. I am now going to say something that one rarely sees in the literature in the counselling industry. I may be labeled a heretic for doing so.

Sometimes clients don’t get better.

This is rarely said, let alone accepted. Psychological theories are so constructed such that there is always hope and always an explanation of why change is not currently occurring and what can be done such that it should. However some clients do not get better or they obtain only minimal positive result to treatment. This is probably a small group of clients but they certainly exist.

These people will report they have spent often years in different treatments including drug treatment, behavioural therapy, insight therapies, spiritual approaches and they have not gotten any better. I am reminded of one woman who suffers from chronic insomnia which she has had for years and no treatment has ever made it any better.


Some clients will try all kinds of different treatments to ease their angst



This is bad enough which leads to the horrible effects of sleep deprivation but sometimes people have suicidal urges which do not get any better no matter what treatment is used. Hence one has the chronic suicidal crisis.

Underlying all the discussion about the woman mentioned before is the assumption that something can be done. Sometimes people just don’t get better and hence the assumption in this case may be wrong. Of course we all like to believe there is hope and a solution but is that to make us feel better or the suicidal person feel better. How long does one persist with treatment that has so far had no positive effect?

It can be very hard to accept that sometimes clients just don’t get better.

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