Psychology and Stress

We’re going to train a male rat in a maze. Our simple maze is shaped like the letter T, and we’re going to place the rat at the bottom of the stem and allow it to run forward to the point where it must choose to turn into one arm of the T, either right or left. To make the choice easy, we’re going to use a rat that hasn’t eaten for 24 hours, and we’re placing 10 food pellets (a good size reward) at the end of the left arm of the maze. The right arm? For now, that arm is blocked off. So, we’re telling the rat, “Want food? Turn left!”

It won’t take the rat long to learn that once placed in the maze, it is appropriate to run to the end of stem and turn left because food is at the end of the left arm. Turning left is reinforced.

For the next phase of the study we’re going to electrify the floor in the left arm. In other words, we’re going to decide that turning left in this maze is inappropriate, and we’re going to punish the rat for doing so. Turning left is the only choice for the rat, but that action will now be punished by giving a painful electric shock to the paws. So, now we have a hungry rat who “knows” there is food at the end of the left arm, but we don’t allow it to get to the food because the shock is too painful.

The rat no longer turns left. Success! Our punishment has worked; we have eliminated the undesirable behavior.

But has the punishment really worked? When you reach in to remove the rat from the maze you better have a glove on because the rat is likely to attack your finger or hand. Similarly, if you place a totally innocent rat in the maze, the punished rat is likely to attack the innocent one.

In short, punishment has produced one pissed-off rat and we have generated the unintended consequence of causing aggressive outbursts in our punished rat. It’s kind of like if your child draws on the hallway wall, you punish him by throwing away his crayons. The poor kid wants to express some creative impulses, but you tell him, “No!” So now he hates you, goes to his room and trashes it, and kicks the cat on the way.

So, what’s missing here? What’s the secret to the effective use of punishment? Simple answer: Punish inappropriate behavior, but also provide for and reinforce an alternative action that can satisfy the motivation behind the punished action.

In the case of our rat, we have decided that we don’t want it turning to the left, so we punish that response. But now, in addition to the punishment for turning left, let’s open up the right arm of the T-maze, and place 1 food pellet at the end of that arm. Granted, 1 pellet is a lot smaller reward than the 10 pellets in the left arm, but there’s no punishment for going after the 1 pellet, and some food is better than none. The cost-benefit ratio of turning right is much better than turning left. What happens? The rat quickly learns to turn right.

The great thing about combining punishment with rewarding an alternative action is that those undesirable aggressive side-effects are greatly diminished. Not only does our rat make the desired response, but he is also less likely to attack your hand or the innocent bystander rat.

By the same token, if you scold your child for drawing on the wall and threaten to take his crayons if he does it again, but follow the threat by giving him coloring books or rolls of newsprint to draw on, you’re giving him a creative outlet while keeping your walls clean. Providing the alternative allows you to say, “No drawing on the walls or there will be consequences; use the coloring books or the newsprint instead.” You can even provide reinforcement by praising his creativity and displaying his artwork on the fridge or in your office.

Punishment by itself is a poor method of behavior control because it says, “Don’t do this!” Punishment by itself doesn’t provide information about what is an acceptable and appropriate action that can still, even if only partially, satisfy the motivation driving the punished action.

So, remember the punishment rule: Combine, “Don’t do this,” with, “Do this,” and remember to reward the latter action when it occurs. Whether in a childrearing context, or in your adult interactions, you’ll find the combination strategy is likely to produce satisfying outcomes for all concerned.

Being dependent on someone has its benefits, as long as your caregiver is reliable. Consider yourself as an infant, for example. You were totally dependent on your parents for virtually everything you needed to thrive: nourishment, safety, comfort, stimulation, and a sense of security. Even as a toddler and beyond, you continued to rely on adult caregivers for your survival, and dependency on them was quite appropriate. It is unlikely that someone said to you when you were 4 years old, “You know, you are really over-dependent on your parents. You need to spread your wings and begin to make your way in the world.”

At some point, however, that comment became very appropriate. At some point you needed to be able to do many things for yourself, to behave and think autonomously and independently, and not always depend on others as if you were still a child. Moving in this direction, of course, can be facilitated or impeded by parents.

I remember my college course on Adolescent Psychology, when one day the professor said, “Being a parent is a full-time job, but a job that must be dedicated to becoming unemployed. Successful parents will work themselves out of a job.” I thought that was pretty cool.

Some parents, however, don’t want to be unemployed. For a myriad of psychological reasons, they feel compelled to monitor, dominate, and direct their children’s activities, sometimes continuing to do so even after their kids become adults with children and families of their own. Such domination and interference can present significant coping challenges; adult children want to be independent and live their own lives, but they don’t want to hurt or offend the parents they love.

In many respects, cult leaders try to establish in their followers the sort of dependency we’re talking about. The idea is to turn followers into blind adherents who will accept as truth whatever the leader says, reject criticism from outsiders as false, and lose all sense of personal empowerment. Coping with challenges becomes virtually impossible without the guidance and direction of the leader. We’re not saying that overbearing parents are the same as cult leaders, but the dynamics and adverse effects on coping are similar.

We can say the same thing about troubled people who enter counseling looking for the quick and magical fix for their problems. They may feel that somehow the counselor is going to wave a wand and, bingo, they will be cured. This type of thinking ignores the fact that counseling is a partnership between client and counselor, and the client must do considerable work if there is to be improvement.

Clients can be guided, but ultimately, they must do the heavy lifting, must believe that what they are doing is worthwhile and will produce success, and must take responsibility for their actions. Many folks fail in counseling because they are unwilling to take autonomous action and work hard to implement suggestions from the counselor. They want the counselor to take care of them, so to speak, to make them better.

Psychology is relevant for people who are emotionally adrift and looking for purpose and meaning in their lives. And, psychology teaches us that if they seek the easy road of total dependence on someone else to show them the way, they will sacrifice the development of the personal empowerment and autonomy needed to take charge of their life. Whether in a cult or in counseling, the result will be ineffective coping.

Note that the dependency does not have to be on a person; it could also be on a substance. A father took his “troubled” 15-year old daughter to a psychiatrist, who prescribed an anti-depressant for the girl. Four weeks later the father called the psychiatrist’s office and complained, “My daughter still won’t listen to me or cooperate. I can’t seem to get through to her. How long does it take for this drug to kick in?” With apologies to Shakespeare, perhaps, dear father, the fault lies not in our stars, but in ourselves! This father has basically surrendered his parenting to a drug.

How about you? Have you surrendered your coping autonomy and independence to another person, or to an artificial agent? If so, what are you going to do about it?

 

Joe is a young adult who has been in outpatient psychotherapy for some time. In the past he has seen two other counselors and two psychiatrists, and taken numerous prescriptions for antidepressants and mood stabilizers, all without much success. He said the psychiatric medications helped somewhat with his depression, but not his unhappiness. His comment reminds us that depression and unhappiness are relatively independent states, although they overlap. Yes, people can be unhappy without being depressed, but clinically depressed people are invariably unhappy.

Joe’s statement that separates his depression from his unhappiness is typical of those who are ambivalent about living. Joe, for instance, describes himself as “smart, funny and attractive,” yet says, “I can’t get myself to feel these ways.” This a very telling verbal signal that anyone having coping problems should watch for carefully: You feel you have many positive traits, but you don’t really experience them in your daily living.

Joe recalls being, in his words, “normal” until reaching the teen years; at this time in his life he remembers becoming unhappy and introverted. “High school was miserable. I’m glad it’s over.”

During his teens Joe was unable to assert his individuality and identity. Independence frightened him and he found it increasingly hard to make decisions and take responsibility for his actions. He felt alone, and reacted with self-defeating and self-destructive actions. He withdrew from others, became dissatisfied with himself, and developed very low self-esteem. “I really felt guilty because I wasn’t growing normally.”

Joe was adrift and had no clear purpose in life. He admitted to never having any dreams or future goals. He said, “I don’t see myself living a normal life.” During one counseling session he blurted out, “I want to be struck by lightning or have some kind of freak accident.”

When asked, “If you didn’t wake up tomorrow would that be okay?” He replied; “Well, yeah, I’d be dead so it wouldn’t matter.”

Asked, “At the end of a tough day, who can you relate to and reach out for comfort?” he replied, “My cats.”

The thing to note here is that Joe’s drift into a purposeless life began in his teen years. Now in his 30s, he has had nearly two decades of approaching life in this lackadaisical way. A lot of habits have had a chance to strengthen, and they will be difficult for him to confront and modify.

The hard thing about Joe’s case is that there are no glaring early childhood issues that seem to have set things in motion. Joe himself said that until adolescence, his life was fairly conventional, “normal.” However, it is clear that during his teen years, a tough period of storm and stress for nearly everyone, he had no guidance from role models who helped him develop some achievement motivation, purpose, and social adjustment.

There are things to work with, though, notably Joe’s description of himself as “smart, funny, and attractive.” His counseling tasks will involve helping him coordinate these beliefs with his actions, and become more assertive in confronting his life challenges.

As a general rule, remember that effective coping requires honest self-discovery and awareness of your strengths. Unfortunately, if you don’t work at translating those traits into productive actions, you will have no anchor to reality. This process is crucial: If you cannot “translate yourself” into concrete actions, you will feel you have nowhere to go.

The young man had the rapt attention of his college classmates when he spoke:

“I was 8 years old, a long way from puberty. I was watching an episode of the old Star Trek TV show from the ‘60s. There was a scene when Captain Kirk had no shirt on, and I couldn’t take my eyes off him. I didn’t feel any sexual attraction, but I just wanted to wrap myself around that chest. Years later as I moved past puberty and into my teens, I realized that I was sexually attracted to guys, not girls. I remember thinking back to my Captain Kirk episode and being surprised; I guess my brain realized I was gay before my body did.”

For two reasons, this classroom comment was not as surprising as you might think. First of all, the student was well-known on campus as gay because he made no attempt to hide his orientation. Second, in class that day we were discussing the psychology of sexual attraction, and had begun talking about whether our attractions were based on conscious choice or an inborn nature present at birth. The question I had posed to the class was simple: “Do you think a therapist could use psychological persuasion techniques to change your sexual orientation?”

After telling his Kirk story, the young man answered my question: “Absolutely not. I did not choose to be gay. It’s who I was at 8 and it’s who I am now. No therapist could possibly change that.”

I asked that question in class many times over the years: “Think about what gender you find sexually attractive. If you decided you wanted to change because the attraction was causing you anxiety, depression, and all sorts of coping difficulties, do you think a psychologist could change you? If you are attracted to the same sex, could the therapist change you so you would be attracted to members of the opposite sex?” In 41 years of teaching college psychology, I asked that question many times, and never did a student say, “Yes.” A fair number said, “No,” but most just sat there, perhaps afraid they might divulge something about themselves. Never, however, did a student say, “Yes.”

To give the class discussion some concrete psychological basis, I would then proceed to describe examples of “conversion therapy” for sexual attraction. Conversion therapies are based on fundamental conditioning principles, and were used on those who were bothered by their sexual preference and wanted to change to conform better to larger society. The basic model was simple: For a homosexual male, combine images of attractive men with pain, and images of attractive women with relief. Unfortunately, even when conducted on a willing participant, the pain part often bordered on torture.

One version of this therapy was called “Playboy Therapy,” and was used in the late ‘60s and into the 70s. A homosexual man would sit in front of a screen. At times, a photo of a naked attractive man would appear on the screen, and be accompanied by a very painful shock to the client. The shock would end when a new picture, a relief stimulus, appeared, a naked Playboy centerfold woman. The idea was to condition the client to consider the naked male disgusting and the naked female pleasing.

Variations of conversion therapies were widespread in the ‘60s and ‘70s when general behavior modification models of psychotherapy were growing and leading to modern-day cognitive-behavior therapy, a technique that is extremely effective for a variety of psychological problems. When applied to sexual preference, however, conversion approaches were, at best, “behaviorism gone wild.” Plus, and most importantly, they didn’t work in changing one’s sexual preference. I repeat: conversion therapies did not work.

Why should they work? Try my classroom introspective thought experiment on yourself: Could you be tortured with pain into changing your sexual preference? I feel pretty confident that whereas torture could help me develop an intense aversion toward my tormentor, there’s no way torture would make me disgusted at the sight of an attractive women, and all tongue-hanging-out-gaga over the sight of an attractive guy. No way.

On the other hand, could mild conversion techniques help me curtail a bad habit (e.g., smoking, alcohol abuse, cursing, driving too fast, not using a seatbelt, etc.)? Probably so, but only if I was strongly motivated to change. But, like it or not, sexual preference moves us to a different arena (born that way) than bad habits (learned, not inborn), and conversion therapies do not produce change.

When used on minors (“Dr, Dr! Help! My 12-year old son says he likes boys more than girls! Change him, please!”), a good case can be made that we’re talking child abuse. As of 2018, fourteen states and D.C. have laws prohibiting therapists from trying to changing a minor’s sexual preference.

Here’s the coping lesson to take from this discussion. If you feel out of the mainstream when it comes to sexual attraction, and if that status causes you anxiety, identity problems, or other emotional difficulties, you would do best to confront your reactions to your natural inclinations. If you deny and try to change those inclinations through counseling, you may be heading down a blind alley that will cause you more problems in the long run. You might do better to go into counseling not to change, but to adjust your thinking about who you are to help you move toward acceptance of that reality. Also, remember that joining an appropriate support group can supplement counseling and be helpful in the acceptance process.

Major themes of this blog site are that you must deal with your problems within a context of acceptance of who you are, deal with those issues that are within your circle of control, and be motivated to develop personal empowerment. Conversion therapy is unlikely to help you with any of those processes.

 

Placebo effect and counseling (2.10.19); Finding happiness and satisfaction (2.3.19); Are support groups helpful? (1.26.19); Do you have a coping plan for a psychological crisis? (1.19.19); Subtle Suicide case study (1.13.19); Modifying your actions (1.6.19).

PLACEBO EFFECT

If you take a pill and expect it to reduce your headache pain, you have increased the odds that the pain will indeed subside. This effect can be so strong that even if the pill you take is simply an inert sugar pill, a placebo, and not a pain-killing medicine, your headache may still go away. This “placebo effect” shows how expectation can have powerful physical effects.

How about a psychological condition that is being treated by counseling? Can the placebo effect operate in this case?

Let’s create a hypothetical situation where two guys, Joe and Bill, live in parallel universes. They both suffer from social anxiety; put them in a room full of strangers and they fall apart, overwhelmed with insecurities, fear, and dread. They each have a friend who has a similar problem and is undergoing counseling for the problem.

In their respective universes, the friend says, “Why don’t you sign up for some sessions with my psychologist? She’s really helping me and might be able to help you.”

Joe says, “That sounds good. If it works for you I bet it’ll work for me. Give me her number. Thanks for the tip. I really feel good about this.”

Bill, in his parallel universe, says, “Just because she helps you doesn’t mean she will help me. But what the hell, just to get you off my back, give me her number and I’ll schedule an appointment. Believe me, though, it’s going to be a big waste of time.”

Note that right out of the gate Joe and Bill have different expectations about how well the counseling might help. Joe is optimistic, Bill is pessimistic.

In their separate universes, Joe and Bill go off to their respective sessions. Afterward, each is on a bus heading home and a stranger sits down in the next seat and starts reading his paper. Joe and Bill each think, “OK, the Dr. says I might try to give a casual greeting to a stranger, just to show myself I won’t drop dead from fear. Here goes.”

Optimist Joe turns to the guy reading the paper and says, “Really hot weather we’ve been having, isn’t it?” The guy turns to him and says, “Yep, sure is,” and goes back to his paper. Joe thinks, “Well I’ll be damned. I actually got a response. I started a conversation and got a reply. This counseling is really working!”

In pessimist Bill’s universe his action and result are identical. He turns to the guy reading the paper and says, “Really hot weather we’ve been having, isn’t it?” and the guy replies, “Yep, sure is,” and goes back to his paper. Bill, however, thinks, “Well I’ll be damned. I reached out and got a big three words from him. What a waste. I tried to start a conversation and basically was ignored. This counseling is nonsense!”

Joe and Bill have identical experiences, but their reactions are quite different. How come? Do we have a placebo effect here? Remember, Joe believed the counseling was going to work. Is it that belief that makes him give such a positive reaction to the three words the stranger gave him? By the same token, Bill never really did believe the counseling would work. Did his negativity dispose him to put the 3-word reply in such a negative light?

When it comes to increasing the likelihood of successful counseling, let’s note that several preconditions are important. First of all, the client must be willing to take an active role in counseling and work hard to produce needed changes in his/her behavior. The client must also trust the counselor and be willing to “open up” to the counselor, and follow recommendations made by the counselor. Perhaps most importantly, the effectiveness of counseling is helped enormously if the client truly believes it will be helpful.

Obviously, this last precondition brings us into placebo-effect territory; that is, believing counseling will work makes it more likely to work. However, I don’t mean to suggest that successful counseling is simply a placebo effect. Notice, for example, that if a client believes there will be a positive outcome, then the client will also be more willing to work hard, stay optimistic and confident, trust the counselor, and persevere when the going gets tough. It is those qualities and actions that result in successful counseling, not some sort of magical placebo effect.

The point here is simple: Counseling is not like taking an aspirin, lying down, and waiting for your headache to subside; counseling requires you to take an active role in your treatment. If you sincerely believe that it can bring you positive benefits, you will be more likely to engage in actions that will bring those benefits.

There is no magic wand when it comes to stabilizing yourself psychologically and coping with life more effectively. You are the agent of change; only you can control your thinking and actions; only you can decide to empower yourself and develop an effective coping strategy. Your success, however, will begin with the belief that you can change.

 

FINDING SATISFACTION

One reason happiness is so elusive is that people tend to center their search around “me.” What do I need to do to make myself happier? The problem here is that you’re being self-serving and looking for a recipe that is defined by your needs, your frustrations, your anxieties, your difficulties.

“But,” you ask, “how can I possibly help myself if I don’t center my plans and actions around myself?”

Here’s a thought: Instead of putting yourself as the main ingredient of the recipe, take yourself out of the recipe. Consider the possibility that, whatever your difficulty, using the emotions it generates within you will increase your sensitivity to others who suffer from trauma and conflicts similar to yours. This empathy will not only help others, but yourself as well. That’s right, taking yourself out of the formula will encourage you to reach out to others. The bonus? You will discover that reaching out will bring you ample helpings of personal satisfaction, and help you cope better with your problems.

Empathy. We usually think of it in terms of helping others. If you have been previously victimized or are presently dealing with emotional upheaval in similar ways as another, who can understand their plight more than you?

The true human beauty of empathy, however, is that both the giver (you) and the taker (the other) reap the psychological benefits. There is no more effective therapy than empathic service to others.

Whatever your plight, you are not alone in your difficulties. The best way to facilitate your ability to cope is to make sure that, as you travel the road to finding personal satisfaction, you leave no one behind. In that way you will find yourself participating in the richness of the human adventure.

 

SUPPORT GROUPS

When we’re faced with the aftermath of a traumatic event, one of the greatest obstacles to coping is when we look inward and attempt a self-analysis. This process can compromise good coping because, more often than not, we enter the world of self-doubt (“Do I have the courage and strength to recover?”), self-blame (“I should have done things differently; the whole event is my fault.”), and self-pity (“I need to let others know how I have been victimized because I deserve their sympathy.”).

These self-intrusions make successful coping with the trauma difficult because you become unable to look objectively and accurately at the event and the challenges facing you. One excellent way to resist these ventures into a self-centered mine field is to join a support group for those who have suffered the same, or very similar trauma. Such groups are plentiful, and can be located by contacting a local mental health association, crisis hotline, or even local law enforcement.

When in the company of victims like yourself, interesting psychological dynamics unfold. Consider the words of support-group members, and note how so many coping lessons that we discuss in this blog can be found in their words:

“Telling my story to others, and listening to their stories, helped me organize the basic facts, the objective reality of the event.”

“I felt less alone.”

“I discovered it was OK to be nervous; OK to feel ashamed thinking I was the Lone Ranger, all alone in my turmoil.”

“I found it was OK to laugh, and talk, and share. There was a lot of all of that in my group.”

“We shared our secrets, our darkest days. I felt a sense of belonging because there was a bond of trust, of privacy, an unspoken understanding that our secrets would never leave the group. It gave me a sense of identity beyond myself, and the security that brought me was unreal.”

“New people would show up. It was hard for me to listen to them because I was reliving my own experience. But the long-term effect was acceptance and a feeling of personal strength.”

“I knew I was reaching an inner peace and strength when it occurred to me that I had become as much a helper in my group as one who needed help. When I shared my story with newcomers I could see it in their faces. There is life afterwards; it goes on.”

“I discovered sympathy and empathy, I mean to the point that I realized it was not all about me. We asked the same questions, faced the same demons, and found lifelines. Since joining my group I have felt more human than ever before in my life.”

We should all be so lucky.

So, what are some of the important coping themes we see in these comments? Organizing a plan to deal with the reality of your issues; realizing you’re not alone; accepting emotions instead of denying them; sharing secrets and trusting.

Two cautions: your group leader should be a professional with experience; and, the purpose of the group should not be to embarrass, badger, or intimidate members.

Roy is 62 years old and is finishing up his annual physical. His physician says, “Roy, everything looks great. Your blood work, vitals, weight, lifestyle…everything is in normal and healthy ranges.”

Roy smiled and said, “That’s always good to hear!” The physician looked at him and added, “Of course you understand that I can’t guarantee you’ll live to 80 or even 70.”

Roy, still smiling, nods and says, “Sure I understand that. But trying to live a long life is not why I exercise, keep my weight down, and all that other healthy stuff. I just want to feel good today! Isn’t that about the best we can do?”

Even though the staying-healthy odds are in his favor, Roy could easily suffer a health crisis at any time, even the next day. And here’s the coping question I want to pose: If it happens, will he be prepared for the crisis?  An unexpected event brings drastic changes to his life and arouses intense emotions that threaten to overwhelm him. Will he be able to keep his head above water? Will he be prepared to have a “crisis conversation” with life?

How about you? Are you prepared to maintain your coping conversations with life in the face of crises? Here are some things to consider when faced with events so intense that you feel you could very easily spiral out of control.

To organize your crisis plan, ask yourself some basic “what if” questions. The idea is not to make up a precise list of steps to take, like a family might do to prepare for a flooding river, tornado, hurricane, or some other natural threat. No, the idea is to formulate a general conceptual plan of basic principles to follow when suddenly confronted with unexpected coping challenges, such as when a loved one dies, sickness occurs, or there is a vital threat to your financial security.

First of all, assess the crisis by determining what features are under your control. A crisis tends to bring out strong emotional reactions, which put you at risk for blindly reacting and trying to influence events that really are far out of your control.

Remind yourself to be proactive using your intellectual abilities and not relying solely on sudden emotional tendencies. Fear, frustration, jealousy, anger and other emotions will tell you to run, avoid, and hide, and such avoidance is a sure recipe for devastation. A more rational approach will focus on how you can use your emotions to your advantage, not on how you can deny the presence of your unwanted emotions.

Bring in your trusted friends, your social network, to help. Communication is essential here, but again, it must not be based on panic and fear. Rationality, objectivity, and a willingness to listen to proactive suggestions from others is essential if your communication is to be productive.

Do not blame others for your crisis. Doing so will distract you from the task at hand. Convincing yourself that evil others are responsible for your travails will only elicit derisive laughs from life. Even your social network will recoil from your displaced blame because you will sound defensive and unwilling to move forward.

All these suggestions are explicitly developed throughout this blog, and they shouldn’t surprise you. The point here, however, is that if you are psychologically and mentally prepared when a “what if” question becomes real, you will be better able to put our blog principles into practice.

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.