Therapy Should Not Focus On Symptoms

Notes on Alice from her new counselor:

Alice’s father drank heavily and used his belt on her often. She remembers being terrified of him when she was a child. She describes her mom—an unstable woman who had a psychiatric history of her own—as psychologically abusive. “Dad’s anger and abuse was mostly predictable. I stayed clear of him as much as possible. Mom’s moods were unpredictable. One minute she could be showing me how to how to bake cookies, but then turn on me saying I was dumb and she wished she had never had me. It seems like I grew up always confused and afraid. Home was like a torture chamber.” More than thirty years after these repetitive disturbing childhood experiences, Alice has been a client in psychiatric counseling with medications, although without much success. She eventually quit her meds and began treatment with a series of psychological counselors, none of whom had much success with her.

She still has nightmares about her early home life. She shows symptoms of post-traumatic stress disorder along with unresolved anxieties caused by fear of abandonment. She 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. She has a long history of alcohol and drug abuse. “Nothing in life gives me the relief and pleasure I get from booze and drugs. I knew they didn’t mix well with my meds, so I quit taking the meds and the shrink who was prescribing them. Crazy, huh?”

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—a hallmark of subtle suicide. 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 has taken many risks and rolled the dice many times in her life and never seems 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 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 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. Her case is an excellent example of the importance of what she and her counselor need to attack. Too often, psychological treatments target symptoms, a focus that 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.