New book released soon

Working with drug and alcohol users, my new book should be out in a few months. Here is a video where I provide a brief monologue about the book. In it I talk about the dependent drug user and how there are three solutions. The dependent user is what is usually seen as the addict type of drug user unlike the recreational user.

As I note in the video the largest group by far are the recreational users but they rarely seek any drug counselling because the drugs do not cause them any disquiet. Instead it is one of the smallest groups (the dependent user) who use up most of the drug counselling resources.

With the dependent user the three solutions are:

Switching the addiction

Growing out of the addiction

Therapeutic solution (which is a variant of the switching the addiction solution)

I talk about AA and that as one way where the the user can switch the addiction from alcohol to the AA organization and philosophy. Here is a snippet from the book where I talk a bit about this.

“In addition Kelly et al (2009) notes other features of AA that are seen to make it more successful. "The main benefit of AA in aiding addiction recovery may lie in its accessibility and its long-term, 'extensive', focus."(p.254) People can have exposure to the therapeutic elements on demand and self regulate the intensity of their self dosing for as long as they desire. AA is also free, usually available everyday of the week most importantly during high risk periods of relapse, a close and at times intense relationship with the sponsor is also a central feature of the AA system. These features fit the criteria of a symbiotic relationship between a person and in this case an organization.” (end quote)

Children are taught to take drugs early on in life.

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Client change

This chart comes from a book that was published in 1978. A basic transactional analysis text at the time. It is one of those things you find in a book that you notice for some reason and kind of never forget. It always struck me as an interesting chart.

It’s great when you get a client who is in the first and second groups and they attribute their change to you the therapist.

One of the reasons I noticed it was that it is based on the assumption that everybody is help-able. That all clients can be helped. It assumes that all people can be helped as long as the therapist’s skill is high and there is enough time and energy put into the client. I have my doubts that this is true at least at times. Some clients at some points in time can not be helped. That can and often does change over time for the same person. For instance a person who is in the 5th 20% is likely, over time to move up the list and therefore become more capable of being helped. I would add a 6th category - at this point in time no change will occur no matter what the therapist does or the amount of energy put in.

Another feature is that it is based only on the client and the therapist characteristics. I would add in a third criteria and that is the psychological condition being presented. Some things are easier to treat than others regardless of the client’s motivation. It is easier to treat a tightwad than a spendthrift. The tightwad does not have enough Free Child and the spendthrift has too much Free Child. People naturally do not like giving up their FC. The antisocial personality is too hedonistic whereas the OC personality is not hedonistic enough therefore the antisocial generally is harder to treat.

Then of course value judgements also creep into what is considered abnormal. It was only 40 years ago that homosexuality was considered by mainstream psychology to be an abnormal psychological state. Some kinds of illicit drug use are considered abnormal behaviour whereas the reason why it is illicit is for political reasons not psychological reasons. Hence they are considered psychologically abnormal because of a political judgement not the natural state of the human psyche. In these types of conditions perhaps one needs to consider more than just the client and therapist qualities.

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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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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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Teenage supervision

Its not a good week to be a parent in the city in which I live. Parents have come under considerable criticism by the police and parts of the press, most notably Jane Marwick in today’s daily newspaper.

As 14 - 16 year olds end the school year they go to holiday resorts and some of them get drunk and so forth. Whilst these are undoubtedly the minority they attract attention from the police and the press. The police in particular are scathing of parents who they say are not taking any responsibility as they put it and letting these teenagers run riot.



One thing the police do not say is how it should be done differently. At some point the teenager has to be left unsupervised. That is how a young person develops a sense of responsibility. If you are supervising them then they are not being responsible for them self and thus can never develop a sense of self responsibility. Sooner or later you have to let them go and do it on their own.

I have been counselling teenagers and their parents for 25 years and I am not aware of another way by which a teenager can become self responsible without being left unsupervised at some point. If Jane Marwick or the police have some idea on how to do that I would be very interested to hear it.

At what point do you let them be unsupervised and to what degree - there is no clear answer. It varies depending on the personality of the child and the relationship with the parents. It is a very difficult path for parents to walk as often it is trial and error and involves changing the plan of teenager management as you find what works and what does not.



At times parenting teenagers involves two bad choices and it is a matter of picking the less bad choice. A strong willed 15 year old who is reacting against parental supervision can simply get up and walk out of the house. You cannot stop them. You can call the police who can find them and bring them home but then they just walk out again. This can only happen a certain number of times before they end up on the streets. A horrible scenario for parents.

Such a teenager is demanding to be unsupervised and most teenagers do this in varying degrees. When I counsel such parents and teenagers the parents again have to walk a tightrope. You certainly don’t want them being on the streets so you have to give them more unsupervised periods than you may like. The parent has to pick the lesser of two bad choices in order to maintain a relationship with the child and some degree of control. If those criticising these parents have a better solution I would be very glad to hear it.



As the relationship transitions from parent/child to parent/teenager a quality of bargaining and negotiation enters into it. Almost all teenagers will do this to varying degrees. If the teenager is of a complaint nature then it may be minimal. If they are of a strong willed adversarial nature then it can be very pronounced. At times parents have to let teenagers do what they don’t want them to do in order for the longer term goals to be achieved.

At some point parents have to let teenagers be unsupervised if they are to grow into functional members of society who can self regulate. Those unsupervised times often involve undesirable behaviour, that is how the teenager learns what is desirable and undesirable.

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Book award party

Last week we had a party for the book award I recently received.

Here is a photograph of myself with the award certificate.


Note the Toblerone and the strawberrys!

Here is what the publisher had to say about the award.

The list of university and college libraries that stock the book contuinues to grow. I must admit that I am a bit surprised at the size of the list as the book is still not even one year old. I would have assumed that psychology, social work and psychotherapy degrees would have to plan more on what texts they would use for next year and so forth.

University of Waterloo (Canada)
University of Manitoba (Canada)
Saint Francis Xavier University (Canada)
University of Victoria (Canada)
Vancouver Island University (Canada)
Ryerson University (Canada)
Royal Roads University (Canada)
Simon Frasier University (Canada)
St. Clair College (Canada)
Universite de Montreal (Canada)
Memorial University (Canada)
Mount Saint Vincent University (Canada)
Mount Royal University (Canada)
Wilfrid Laurier University (Canada)
Cambrian College (Canada)
Kwantlen Polytechnic University (Canada)
University of Lethbridge (Canada)
Concordia University (Canada)
University of Guelph (Canada)
Library and Archives Canada (Canada)

Maribor General Hospital Library (Slovenia)

Stellenbosch University Library (South Africa)

Mitt hogskolan library (Sweden)
Stockholm University (Sweden)

PJ Library (Norway)
University of Bergen (Norway)
Norges teknisk-naturvitenskapelige universitet (Norway)
University of Oslo (Norway)
University of Tromso (Norway)

Freie Universitat Berlin (Germany)
Humboldt University of Berlin (Germany)
State and University Library of Dresden (Germany)

University of the West of England (UK)
Derbyshire library (UK)
University of Plymouth (UK)
Manchester Metropolitian University (UK)
Lancaster University (UK)
University of Hull (UK)
University of East Anglia (UK)
University of Cambridge (UK)
Oxford University library (UK)
University of Exeter (UK)
Coventry City Council library (UK)
Bromley Library service (UK)
Cadbury Heath Library (UK)
Kingswood Library (UK)
Nottingham Central Library (UK)
Yate Library (UK)
British Library (UK)
Ebook library London (UK)
Hounslow Library (UK)
Barnet London Borough Library (UK)

National library of Scotland (Scotland)

University of California San Diego (USA)
Open Library. California State Library (USA)
University of Washington (USA)
Norwich University (USA)
Ithaca College (USA)
Marquette University Raynor Memorial Library (USA)
University of Massachusetts Amherst (USA)
Williams College Massachusetts (USA)
National Library of Medicine Maryland (USA)
Illinois State University (USA)
Loyola Marymount University California (USA)
University of Michigan (USA)
Central Michigan University (USA)
University of North Carolina Chapel Hill (USA)
University of Missouri-Columbia (USA)
Akron-Summit County Public Library, Ohio (USA)
University of California Merced (USA)
University of North Carolina Greensboro (USA)
Library of congress (USA)
University of California San Franisco (USA)
Mt. Hood Community College Library Oregon (USA)
National College of Natural Medicine Oregon (USA)
Oregon Health and Science University (USA)
Northeast WI Public Libraries (USA)
College of DuPage Illinois (USA)
Boston College (USA)
University of Chicago Illinois (USA)
University of North Texas (USA)
Laredo Public Library Texas (USA)
University of Texas-Pan American (USA)
University of Texas at Austin (USA)
University of Puget Sound (USA)

Executive Counseling and Training Academy (Singapore)
Ngee Ann Polytechnic Library(Singapore)
Singapore Polytechnic Library (Singapore)
National University of Singapore (Singapore)

LaTrobe University (Aust)
Murdoch University (Aust)
Monash University (Aust)
Victoria University (Aust)
Bankstown Campus library (Aust)
University of Sydney (Aust)
Queensland University of Technology (Aust)
Deakin University (Aust)
University of Adelaide (Aust)
University of Western Australia (Aust)
University of Ballarat (Aust)
University of New England (Aust)
University of Western Sydney (Aust)
Charles Sturt University (Aust)
Curtin University (Aust)
Australian Catholic University (Aust)
University of Newcastle (Aust)
Bond University (Aust)
University of Melbourne (Aust)
James Cook University (Aust)
National Library of Australia (Aust)

Trinity College Dublin (Ireland)
Dublin Institute of Technology (Ireland)

University of Auckland Library (New Zealand)
University of Canterbury (New Zealand)
Lincoln University (New Zealand)
Northtec library (New Zealand)
Auckland University of Technology (New Zealand)
Unitec Institute of Technology (New Zealand)
Eastern Institute of Technlogy (New Zealand)
University of Otago (New Zealand)
Rotorua District Library (New Zealand)

City University of Hong Kong (China)
National Cheng Kung University (Taiwan)



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Strengthening the Adult ego state

Today is Saturday and that means laundry washing day for me. Hey I am a regular kind of guy! As I embarked on this most OCD of all OCD tasks I discovered that my laundry powder had run out so I went to the supermarket to buy a new box of clothes washing laundry powder.

When I got there I was confronted with this wall of different types of laundry powder boxes all different shapes and sizes and colours all claiming different sorts of things. I thought

“S**t, all I want is a box of washing powder and I am going to have to make 30 decisions to end up with the one I want”.

Now I know what home work exercises to give my clients who are tormented with indecisiveness. To hone their decision making skills just go and buy some laundry powder.



So I started the process and decided on the size I want and the kind of money I want to spend. The rule of thumb with this kind of product in the supermarket is never buy the cheapest as the quality is crap. Also never buy the most expensive as they use the psychology that people will assume it is the best quality when it is no better than the average priced brand.

On a side note sometimes people ask me about how to pick a therapist, to which there is no easy answer but there is one thing I tell them not to do. Never pick the one with the biggest and most expensive advertisement. Now if one is choosing a plumber or an accountant it may be OK to pick the most expensive advert. But in choosing a therapist there is something not just right about the one with the most expensive advert. I can’t articulate why it’s just an intuitive conclusion. Having been in the counselling industry for 30 years, to me there is just something wrong with a therapist who presents self in the biggest advert.

However back to the topic at hand. I finally reached the point where I had decided on two possible items to buy. One was called Bam and the other was called Blast. That was my choice - Bam or Blast. Who thinks up these names? Some psychologist would have done a PHD on this. Someone would have received a doctorate for a study on the marketing psychology of laundry powder and concluded that names like Bam and Blast are the ones that would sell. Hey it worked on me!


OCD



Also as I pondered this decision one is confronted with a paradox. There are questions one muses over such as what does my life mean and who am I? And then I realise I am in a supermarket pondering on which product to buy - Bam or Blast!

So I made my decision and Blast it was. However there was still one decision to go. What scent do I want - lemon or frangipani? Do I want to smell like a lemon or smell like a flower when I wear my clothes? Last time I chose lemon because it seemed more manly to smell like a lemon as compared to a flower. But this time I chose frangipani because of late I have been developing my feminine side.



Today I have been walking around smelling like a flower. And after all that decision making I feel like I have to have a valium and have a lie down.

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Kahless script currency analysis

Results



One and only ++

Reverse status ++

Drugs ++

Booze ++



Analysis





Booze and drugs



Games: alcoholic, cops & robbers

Psychosexual stage: Oral

Lifestyle/occupation: Gourmet, wine taster, narc, temperance league, junkie

Illnesses: Gastrointestinal, oral problems

Therapist: Addiction counselling

Personality: Antisocial, schizoid, narcissistic

Issues: Can be more severe in terms of life threatening, despair rather than depression









Tends to result from pre-verbal quite early problems with the primary attachment figure. Primary attachment figures may be emotionally absent in some way.



May have a tendency to move to a position of non life if not obviously self destructive. Stroke deprivation can result when the individual enters periods of incapacitation (non life) which may last many months.



Possibility of openly self destructive behaviour with the use of alcohol and drugs but also by other means as well. Possible suicidal urges.





The sophistication of smoking Peter Styvestant thins.





Quite amenable to psychotherapy but needs to find a good attachment figure in a therapist. If achieved then considerable psychological gains can result but it takes time.



Needs to structure life such that social isolation does not result even though there maybe a constant pull to that position.



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Two chair in the therapeutic process.

In this procedure the client projects some aspect of their personality out onto an empty chair and then dialogues with it in some form or the therapist can dialogue with it in some form. This can add an extra dimension to the counselling process.

A good deal of the usual counselling process involves presenting something to the client that may be new and then waiting for the client to do something with it. In this way it can be seen as a passive process.



This diagram shows how the therapist can present a variety of new or different actions, communications or relationship styles to the client. Once done the therapist then remains inactive to see what the client does with them, if anything. It is hoped that the client will take them and then alter something within their personality thus leading to psychological change. However as far a the therapist is concerned it remains as a hope. The therapist simply has to wait and see.

Two chair techniques allow the therapist to be more active. It allows the therapist to actually directly delve into the personality of the client. To get right into the personality of the client and change things around by stimulating various parts, highlighting them to the client and so forth. It also allows the therapist to establish relational contact directly with various aspects of the client’s personality.



This diagram shows that with the client’s permission the therapist can move beyond the exterior of the client’s personality and delve into the actual personality of the client using therapy processes such as two chair.

An important aspect of two chair is that the person does not take the role of the other party. If a client puts his mother in the other chair and then moves to be in mother’s chair he is not role playing mother. In that chair he is being the projection of his introjected mother. It is part of his personality in the chair not his memory of mother. In psychodrama one can role play other parties. In the two chair being described one is being part of their own personality in the other chair and not playing a role.

Two chairs techniques are also regressive techniques. It encourages the client to regress into their Child ego state from many years ago. This is a good thing as it provides a relatively easy way to get the Child ego state into the therapy room which should happen in most sessions. Generally speaking the focus of therapy is approximately:



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Goals of therapy - practical

Kahless says:

Well I look at where I am at the moment. I am in my early 40s. I exist in a state of not happy and not unhappy thanks to the medication propping me up. I am thankful to the anti depressants that I am not in that low point of nothingness that I felt earlier this year.
I don't know what I want not what I don't want. You suggest a don't get my needs met injunction, but I don't even know what my needs are. I am by most people's standards, successful. I don't have to worry about money and I have a successful career and am in stable relationship with a partner who cares deeply for me.
But I am not happy. I do not know what will make me happy.

--------------------------

Her comment raises three interesting points for me.
I will address the first one here and do the other two at a later time.


I saw a piece of research once that outlined the best predictors of the outcome of psychotherapy. Or the importance of things in psychotherapy. It isolated three aspects of it
1. the techniques employed
2. the relationship between client and therapist
3. the practicalities of one’s life at the time

The results were something like
1 = 20%
2 = 40%
3 = 40%



However you can’t quote me on this because I can’t find it so these may not be fully accurate. I recall looking at it and being a bit surprised about the practicalities of life being that influential, but after some consideration it does make sense. This includes things like having a decent income, having relationships in life that are reasonable, living circumstances are OK such as having a home that is reasonable, diet that is OK, having a social life and so forth.

The more one has of these the better the prognosis when the client enters therapy. This is a bit sobering because it is easy for therapists to get lost in their fancy therapies and fancy techniques and so forth. It notes that therapists should initially at least focus on such practicalities in the treatment plan. This may seem a bit basic, and it is, but it is most important at least at times.



Many years ago I recall working in drug rehab with this guy who had a long term heroin problem. He was a nice guy and we established quite a good working relationship over some time. I recall we used to laugh a lot together. At one point he came into quite some money. Of course I did not ask how he came across the dollars, I just noted that he did.

Since our first meeting I had noted that his top front teeth were not too good, being quite discoloured and somewhat decayed. He had never mentioned them as a problem. I was the one who brought it into therapy. I suggested that he use some of the money to have his teeth repaired, whitened and so forth. He responded that he did not care what his teeth were like and he was unconvinced by my suggestion. I persisted with the suggestion through a couple of sessions and he finally did seek out the appropriate dental work, had it done and it did look decidedly better. Whilst I did think it was a good idea, one reason I suggested the dental work in the first place was because if he did not spend the money on his teeth it is highly likely that it would go on drugs.

However the surprising thing was the therapeutic results that it caused. He said that after it was done he felt so much better about himself. He reported that when ever he looked into the mirror he saw a reflection of himself that he liked. He had not not even aware of how this had effected him for so long. That he had disliked the image of himself every time he looked at it almost everyday.



I have never forgotten that. I could have spent my time doing fancy relationship building and fancy techniques to assist him to express his anger at his mother and so forth, when one of the things which turned out to be significant in the therapy was getting his teeth fixed. Something that simple. One of the simple practicalities of life turned out to be a significant factor in his recovery.

And my point is?

When Kahless says:
“I don't have to worry about money and I have a successful career and am in stable relationship with a partner who cares deeply for me.”

I know this is a good prognostic sign should she ever decide to take up therapy with a male therapist

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Doing bad therapy - Therapist role

Major and I, have both discussed how at times the therapist can believe things about clients which are factually untrue. For some reason the therapist comes to some conclusion about the client such as a diagnosis which is not accurate. Obviously this is not a good thing. If a diagnosis is incorrect then of course the treatment is not going to be productive and bad therapy will ensue.

This diagram shows how therapists make diagnoses of the client. It is a function of the Adult ego state (A2) and the Little Professor ego state (A1).



Therapists are making diagnostic conclusions all the time. This can be formal diagnoses such as OCD, PND, DID, PD, ADD. (that is an awful lot of Ds) or all sorts of little diagnostic conclusions in each therapy session. What the body language may be saying, the client maybe seen as minimising, rationalising, displaying racket feelings and so on many, many times each session.

It seems safe to say that all therapists will believe things about clients that are not true. Most often they are things which are not of any great significance. Occasionally they are and then there is a problem.

Over the years I have received referral notes from a whole variety of different professionals. At times the referral note includes a diagnosis of the client being referred. After getting to know the client a bit I sometimes find my diagnosis is different to the referrer. We both can’t be right.


What is the diagnosis?

Diagnosis involves receiving Adult information and then making conclusions based on that. However as this diagram shows humans receive a huge amount of information unconsciously. In Transactional Analysis terms this information is processed by the little adult of the Child ego state (sometimes referred to as the Little Professor ego state). If therapists use this in their diagnosis then they are using hunches and feelings to decide on the diagnosis.



At the Adult ego state level misdiagnosis can occur because there is misinformation, a lack of information or the therapist is mistaken about what the information means.

Diagnosis with the A1 unconscious information is a double edged sword. It can result in more swift and insightful diagnoses but it also has the potential to go more awry than an A2 diagnosis.

Each of us also have our blind spots - our own personal issues and script. Some people see sexual abuse every where, if one has personal issues about the opposite sex then diagnosis in couples counselling can be way off, people who lack a sense of trust themselves will tend to see trust issues more often in their clients, or alternatively they may miss an obvious diagnosis of trust issues.

Another cause of misdiagnosis is inter-professional rivalry - “My theory is bigger and better than your theory”. In some circumstances there is considerable money, power and prestige invested in making certain diagnoses and particularly believing in a particular aetiology for the diagnosis. One needs to be careful that their Child ego state does not take over here and the client suffers or becomes secondary to proving ones diagnosis for professional pride. A diagnosis must always remain changeable in the mind of the diagnostician, when one resists such a change it is necessary to look at ones real motives.


Unruly child = ADD?

Psychology is subject to fashion and trends like any other area of human endeavour. There will be fashions in diagnosis as well. An example of this is ADD. Once upon a time ADD was a discrete and identifiable diagnostic condition. In recent years in Australia it has become a very fashionable diagnosis and now any unruly child can be diagnosed with ADD. Another example of this is the diagnosis of drug induced psychosis. This is a very politically correct and fashionable diagnosis in Australia at this time. Hence it is over diagnosed and thus the therapist believes something about the client which is untrue.

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People’s expectations

I had another person ask me the other day about this video that I have on my YouTube. Why did I do it, how I did it?



The glasses, the solarized effect and the apparently odd manner of my presentation on a serious topic like panic attacks. People apparently who know me or have seen my work as a psychologist in some way expect a video presentation of a more ‘professional’ style. So I get asked why did I do it like that? To which I answer, there is an old rule of psychotherapy - don’t give people what they expect. Its really a rule of human communication in general - don’t give people what they expect.

After they hear this explanation they seem to be satisfied because no more is said or asked by them. This has struck me as a bit odd because my answer I think begs another question - why not?

Why not give people what they expect?



If anyone ever asked me this I am not sure what I would answer. My first thought is that it would depend on the situation where the unexpected communication occurred. In psychotherapy I think it certainly has its place. If a client comes to therapy they will have an expectation of what is going to happen what they will say, what I will say and so forth.

If they leave with what they expected then the session was OK to average, to not much good. If the person gets what they did not expect in the session then it is much more likely that the session was more effective. Of course not every session a client attends can provide some kind of profound epiphany. But in the overall approach there needs to be at times unexpected communications by the therapist.

This will stop the therapy becoming routine. In one way psychotherapy is about unbalancing the client or putting them in a state of disequilibrium. They enter therapy with a psyche or psychological makeup that is a functional whole. That functional whole may be causing them pain but it still is a functional whole. If therapy can destabilise that functional system then the parts of that system are more able to be rearranged such that a new structure is obtained. That new structure can then lead to less pain being experienced by the individual. It seems reasonable to conclude that if the client gets something they did not expect then that will have a destabilised effect.



Society is like personality. Revolution destabilzes it. Once done then change is more likely to occur. Psychotherapy can be seen as creating a revolution in the personality.



Another reason is something far less ethereal and recondite. It gets the Free Child of the client into the room and that is something you certainly want in therapy. If that video was of me standing there is psychotherapist type clothing, in a psychotherapist type manner in front of a white board with a pointer what ego states of the viewer are going to be elicited. Probably Adult with maybe some interested Child if the topic of panic attacks was of interest.

Because of my presentation I would suggest that much more Child ego state in the viewer is elicited. First they are far more likely to remember it than if it was done in the other way. As indeed would happen in a therapy session if something unexpected happened. If I can get the client’s Free Child into the communications with me that is a very good thing for a successful outcome for the session.



However we now have another problem. Because I have let out one of my trade secrets people will now begin to expect the unexpected. Thus we end up back to where we were before.

However there are ways and means to deal with these things and I can’t tell all my trade secrets. Well not all at once.

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The male anorexic

Last year I ran a workshop in Serbia where I did an in-depth examination of anorexia nervosa and a variety of other clinical states. At the beginning of each different condition I gave the usual statistics about the condition. For anorexia one was that 95% of anorexics are female.

A little later on in the workshop one of the participants asked me about the nature and psychodynamics behind the male anorexic to which I had to answer that I did not know. I cannot recall ever reading such a thing nor recall ever working with such a person.

Well as it happens in the last month I have a new client who could be considered to have some of the criteria of anorexia and he is male. As you can imagine he is of considerable interest to me. Upon some reflection it seems that the way anorexia is currently defined it rules out the vast majority of males. So one reason why 95% are female is simply because how the condition is defined.



Thus one could argue that there are indeed more anorexic males but they are not diagnosed because of how the condition is currently defined. Its not that male anorexics don’t exist its simply a definitional problem for the condition that is heavily weighted towards the female psyche.

The usual criteria of anorexia is:

Refusal to maintain a minimal normal body weight for age and height
Intense fear of gaining weight or becoming fat
Disturbance in the way one perceives ones body weight, shape and size.
In females the absence of at least three consecutive menstrual cycles.

This man is in his late 20s and is currently quite thin. He reports that he has had trouble gaining weight since his late teens. At times he has been dangerously thin. He has never been hospitalised but he has always led a very isolated life so he is unlikely to be identified as in danger of dying. He reports that he simply does not eat. There have been times where he has eaten nothing for up to 5 days at a time.



He states that this is a rebellious act as in childhood mother was very forceful about him and his siblings eating all their food at the dinner table. There are many memories of mother demanding that he eat up all his food. Physical punishments were used when food was not correctly eaten. He has a low self esteem, a self hatred and passive suicidal urges. That is he does not actively plan suicide attempts but he has consistent and strong wishes that he was dead.

If one looks at the four criteria of anorexia, obviously number 4 is about females. Number 2 & 3 one could argue are much more female oriented. As a group women are more interested in how much they weigh and about their body shape and size. One simply has to survey the media and one sees endless images about female weight, body shape and size. In comparison there are very few images involving men. Cosmetics, clothing, plastic surgery all indicate the same. That women are much more focused on weight, body shape and size compared to men.



As a result one could say that the current definition of anorexia is sexist. Very few men are going to meet the criteria because the intense focus on body weight, shape and size is much less common in the male psyche.

However there maybe men out there who refuse to maintain a minimal normal body weight for age and height but the other criteria are different. Maybe I have begun to identify some of the other criteria with my single male client. Low self esteem, self hatred and suicidal urges. He is but one person and thus one is most cautious in generalising. However, when I run my next workshop on eating disorders and I get a question about the male anorexic I can now at least give a partial answer.

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Singapore workshops

Last week I ran four workshops in Singapore.

Here is a picture of the organizing committee.

From Graffiti

To my left and right are Jessica Leong (President of TAAS) and Irene Yong. Both these women were instrumental in developing Transactional Analysis in Singapore in the early 1980s.

I ran one workshop on personality disorders to the psychatric staff at the Tan Tock Seng hospital.

Then two demonstration therapy groups to the students at ECTA who are seeking their Masters as psychotherapists and counsellors.

Finally I did a workshop on suicide and the suicidal client. Below is a picture of me being introduced at the start of that workshop.

From Graffiti

Met lots of old friends whilst I was there and made some new ones.

It was a great trip!

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Why are some drugs legal and others not?

I bought a new book the other day on addictions counselling. It is quite good and has some useful information in it. It is the usual sort of thing reflecting mainstream thinking on the topic at the moment. In chapter two it makes a statement that one would not uncommonly find in such a document.

“Contrary to popular belief, most people who use substances do so in ways that cause them relatively little harm”
(end quote).

Why would this be so? Not that it causes relatively little harm but that it would be contrary to popular belief. Why would the wider community have a contrary belief to this?

There are a number of reasons for this which in part answer the question which is the title of this paper. The Australian Psychological Society (APS) has done a position paper on substance use. Now the guys that put these position papers together hard nosed MFs, who eat, sleep and s**t science. You can be sure they know the area very well, they are relatively free of any political pressure so you are going to get a pretty good statement about the science of the area under investigation.

To quote them:

“In Australian history, laws regarding the legality or illegality of certain drugs have been politically driven, and had little to do with the level of use or possible harms that the substances themselves might cause.” (p3)



This creates a problem for government because they say to the public that they are making some drugs illegal because they are dangerous to people’s health. They profess that it is a health issue and what they are doing is for the good of the public. Unfortunately this is not so. They are doing it at least in part for their own political well-being not for the good of the public.

To sell this to the public they then have to set about demonising illegal drugs. They have to exaggerate the dangers thus trying to convince the public that they are acting for their well-being and not for their own political survival.

Thus they demonise illegal drugs in all sorts of ways and hence one ends up with the contrary belief in the wider community that I mentioned earlier. The general public believe illegal drugs are much more dangerous than they actually are and the government has made them illegal to protect us.



From a pure lethality point of view consider this chart below. This was put together by two psychologists who work at Liverpool University in the UK. They looked at the official causes of death through the 1990s and then calculated the risk of death per 100,000 people. They came up with a chart that shows which things are risky for us and which things are less risky for us. Included in it are various drugs.

Very high risk
Tobacco, methadone, injecting drug use, BASE jumping, grand prix racing, cancer, heart disease, space travel

Quite high risk
Heroin, Morphine, barbiturates, alcohol, hang gliding, parachuting, motorbike racing, sudden infant death, working in mining, asbestos poisoning, strokes, prostrate cancer, shaking of babies, off shore oil work

Medium risk
Solvents, benzodiazepines, motor sports, water sports canoeing, diabetes, skin cancer, influenza, suicide, giving birth, helicopter travel, liposuction, working in farming, being in police custody, working in construction

Quite low risk
Ecstasy, MDMA, speed, cocaine, contraception pill, GBH, fighting sports, snow sports soccer & rugby, Asthma, AIDS. meningitis, cervical cancer, food poisoning, air travel, being murdered, chocking on food, electrocution, drowning, passive smoking, factory work

Very low risk
LSD, magic mushrooms, viagra, fair ground rides, swimming, riding sports, food allergies, syphilis, malaria, appendicitis, pedestrian crossings, clothes catching fire, falling out of bed, vaccination, abortion, storms, terrorism

Extremely low risk
Marijuana, cannabis resin, indoor sports, playgrounds, peanut allergy, measles, insect stings, copulation, starvation, dogs, lightening, nuclear radiation, police shootings

Negligible risk
Caffeine, nitrous oxide, ketamine, computer games, masturbation, small pox, leprosy, sharks, cats, meteorites, executions, volcanoes




If the government was acting purely for the health of the community it would change the laws on which drugs were illegal. It would make tobacco and alcohol illegal and make marijuana, LSD and ecstacy legal. There is as much chance of dying from ecstacy as there is from choking to death on your dinner or being blown up in a plane by a terrorist. In addition as far as drugs go marijuana is the safest drug you are going to get.

Then some will argue that marijuana may not kill you but it can make you go crazy with a cannabis induced psychosis. Unfortunately as time rolls on the science has simply not backed up this hypothesis. Yes it is very unwise for a person with a propensity for psychotic symptoms to use marijuana and the vast majority of marijuana users will suffer no mental health problems at all. Hence back to the original quote from my newly purchased addictions counselling book and the APS position paper.

Is a government going to make such legislative changes with illegal drugs? I don’t think so. If they did they wouldn’t be in government for very long which is why they have to exaggerate the dangers of illegal drugs and thus mislead the public in this way. Pretend to act for the good of the public when they are actually acting for their own political survival.

However despite all the politics this does raise some interesting questions for the drug counsellor and indeed parents of children who may use drugs. Does a drug counsellor (or parent) use scare tactics with the client (child).





One way to try and stop a person using drugs is to make such a thing very scary for them. Get them to believe that drugs are much more dangerous than they actually are so they get scared and don’t use. Commonly known as scare tactics.

To do this you have to lie to them even if only lying by omission. Is it OK and therapeutic for a counsellor to lie to a client? Most would argue no. To my mind you have to tell the drug user the truth even when you don’t like what the truth is.

If you tell them that marijuana can make people go crazy the first thing they will do is make their own observations. With the vast majority of marijuana users they will think - “Well I have smoked marijuana and I haven’t gone crazy”. Then they will look around at all their marijuana using friends and see that none of them have not gone crazy as well. After making these observations what is the drug user going to think - “My counsellor is lying to me”, as indeed he is.

As a result trust is broken, the therapeutic relationship is damaged and the counselling suffers, at times significantly. Besides this most drug users have heard it all before anyway. Their parents, teachers, the police, the press, the government and drug counsellors have all exaggerated the dangers of drugs to them many times before. So if you, the current drug counsellor comes along and tells the user the truth and the WHOLE truth they are going to be surprised and maybe even shocked by such a transaction from you. Thus the therapeutic relationship is placed on a much more robust footing and the drug counselling is more likely to be successful.


If you lie to the teenager can you expect them to tell you all of what they are doing?

In particular they are more likely to be truthful with you about what they are doing and why they are doing it. Can you really expect a client to be truthful with you, the counsellor, when you are lying to them in the first place. If you lie to them you have to expect them to lie back to you.

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Family structure and child development

Emeshed and distancing families

Families are structured in differing ways and here I look at two varying structures and the psychological consequences of those structures on the child’s psychological development.

There are emeshed and distancing families. They can be diagrammed as such.

Emeshed family

Scary outside

Distancing family



These can be seen to be the extremes of the continuum with the ‘normal’ family existing in the middle. The closer the family is structured to represent the end points of the continuum the more maladaptive psychological consequences there will be for the child growing up in them.



Emeshed family
The diagram shows the family members represented by the circles. In this family there is a very clear boundary between the inside of the family and the outside and the member have a sense of closeness and belonging but overly so. There is a script belief by the family, “Don’t trust” others (outside the family). There can be paranoid beliefs about non family members. “Us and them” thinking. The world outside the family is seen as a scary and dangerous place and you can only trust family - is the ethos.

Group think creates self perpetuating beliefs. Along with the introjection of beliefs particularly about others. This can result in fighting with others out side the family. Neighbourly disputes over fences or barking dog. Family feuds use the group dynamics of the combat state which can foster a strong emeshed family structure.

There can be faulty thinking - grandiose delusions about the specialness of the family or one member may be identified a special due to what is believed to be exceptional ability (sport, music academic), appearance, power, wealth and so on.



Family gatherings such as birthdays, holidays, christmas and so forth occur regularly and non attendance is viewed in a very dim light. There can also be (but not always):

Infantilization of the children
Excessive contact - sleeping together, working together, socialising together
Prevention of independent behaviour
Parental - system control. Intolerant of variation or deviation of the members where members do not behave how they are supposed to. A child who refuses to eat dinner, performing poorly at school or a parent displaying anger, power being challenged. The response to correct deviations are swift and intense by other family members.

Distancing family
In this instance there are tenuous connections between family members and often there is no contact for long periods of time. There is little sense of belonging and the family being a close knit group with a clear sense of boundary between it and the rest of the world.

No sense of belonging or community leaves people feeling isolated. There can be one person who holds the family together and when they die or move away the family disintegrates. Don’t belong injunction.

Little interest or frequency of family gatherings. Can easily geographically move away from each other and there are long periods of little or no communication with few protests from anyone.

The distancing family tolerates variation and deviation to the extent of not even noticing or caring. Responses to variations may not even occur even when required such as with a truanting child.



Mixture
Mixture of family structures can occur at times if there is a number of people like in-laws cousins and so forth. One get subgroups in the family that can be structured like this.

Potential problems resulting form these structures
Emeshed
Relationship problems - Spinsters, bachelors & divorcees. Children may have a series of failed relationships that never work. No one is ever good enough for me or they all have some bad point that negates them as a potential partner. Maybe a short dysfunctional marriage may occur. A long term affair with a married man is another possibility (ie selecting an unavailable partner). When these relationship end where do they go then? Go back to the family of course.

This raises a point that I sometimes see in counselling with those who are entering a stage where marriage is in the foreground. When you marry someone you marry the individual person but you also marry their family structure all their attachments and relationships as well. The family structure and attachments were there long before the potential spouse came along and these things tend to be inert and do not readily change. Indeed in an emeshed family they are very resistant to change. If one is marrying into an emeshed family structure they better get used to the idea and it will take them a long time to be fully accepted into the family structure. Sometimes they never are and will always seen as an outsider to some extent.


Gothic wedding

This raises the issue of a person’s motivation for marrying a spouse. People get married for lots of reasons. The overt reason is because they have fallen in love with the partner and want to spend the rest of their life with him/her. Underneath there can be a whole variety of other covert psychological reasons.

People from an emeshed family can marry to get out and away. They see it as one of the few ways to get out of an oppressive family system especially when the newly weds geographically move away from the original family unit. The family will use all sorts of mechanisms to stop this happening such as financial ties, gifts, emotional black mail and so forth.

If you are marrying a person from a distancing family one may wish to consider such possible motives of their partner. It also works the other way. People from a distancing family can marry a person from a ‘closer’ family because they crave the feeling of belonging to a family. In their mind they are marrying the family attached to the partner just as much as they are marrying the partner, if not more so.

Other problems that can result from an emeshed family
School phobia
The child who is aggressive or unpopular to his peers ends up isolating self
Enuresis & encropesis = cannot stay away from home over night with out complications and embarrassment
Paruresis
Anxiety disorders - agoraphobia, panic attacks, means of travel such as a fear of flying or public transport. Any kind of anxiety that makes movement away from the home or family difficult can have some of its basis in the emeshed family structure. It should be noted that there are also other causes of these problems. However if a client presents with this kind of problem then the counsellor needs to investigate the type of family structure the person grew up in.



“Leaving home” problems are typical of the emeshed family. When the children reach the age where they are ready to (supposed to) leave the home and family. Twenty somethings or thirty somethings. When the family reaches this developmental stage it can restructure it self to make one or more of the children an identified patient. The young adult develops a problem like a drug problem, becomes suicidal, develops a mental illness of some kind, or something else like anorexia or other kinds of eating disorders.

When this happens the family bonds together for the good of the identified patient when the real reason underneath is to propagate the emeshment.



Distancing
The schizoid personality type is the most obvious product of this type of family structure. There may be a sense of despair due to lack of emotional attachment, commitment phobia and difficulty with forming close attachments. The ‘gypsies’ of the world who can travel and never really settle down into some kind of group or family unit. At times some find drugs can fill the void of the lack of attachment.

The anti social or narcissistic personalities can also manifest from this kind of background. Both these have attachment difficulties and either don’t understand what attachment is or simply find human attachment too overwhelming.

As mentioned before sometimes these people can attempt to solve their distress by marrying a family. The man may actually be attracted to and in love with the woman's family more so than her. This may lead to marital problems later on.

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