Alice’s father drank heavily and used his belt on her often. She was obviously afraid of him. She describes her mom as psychologically abusive, an unstable woman who had a psychiatric history of her own. More than thirty years after these disturbing childhood experiences, Alice still has nightmares about school and her early home life. Thus, she shows symptoms of post-traumatic stress disorder (PTSD) along with unresolved anxieties caused by fear of abandonment. For a number of years, Alice has been a client in psychiatric counseling, including medications, although without much success.

Alice has a long history of abuse with alcohol and drugs. She says nothing in life gave her the relief and pleasure she received from alcohol. She knows drugs and alcohol do not mix well with psychiatric medication, so she tries to avoid taking medication as much as possible.

She has trouble sleeping, complains of issues in areas of anger, anxiety, and depression, and shows pessimism and marked sensitivity in relating to life and people. She cannot handle criticism from others, and takes it as a personal attack and sign that she is incompetent and worthless.

During adolescence and early adulthood, Alice developed a strong indifference to her health and survival. To put it bluntly, she didn’t care if she lived or died. Drugs and promiscuity became the major players in her life. Although she never went to jail, she was routinely involved in drunk and disorderly episodes. Remarkably, she avoided major setbacks for many years.

Although she never tried to kill herself, Alice is intensely ambivalent about living. She took many risks and rolled the dice many times in her life and never seemed to care what the outcome might be. She trusts no one. The built-in will to survive keeps her alive, barely, but overwhelmingly negative thoughts and emotions produce a risky, self-defeating, and self-destructive lifestyle.

Alice’s life shows unmistakable signs of subtle suicide, characterized by a steady descent into a black hole of self-sabotaging behavior. After thirty years of practicing this lifestyle, her prognosis is not good because her core conflicts are so well established.

In the past her counselors have tried to help her attack her alcohol and drug abuse, but those are just symptoms. Alice needs to confront her core conflicts: fear of abandonment; inability to trust others; anger and self-blame for the psychological abuse she suffered as a child; and internalizing criticism from others as symbolic parental attacks on her competence and worthiness.

Alice’s case is an excellent example of the importance of what she and her counselor need to attack. Too often, the treatment emphasis is on symptoms, which ignores the deep-rooted conflict that causes the symptoms. Unfortunately, with Alice this core has been ignored so long, her personality dynamics and action patterns designed to service the root conflict have become entrenched. Replacing them will not be easy.

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