Alfred AdlerIn unified psychotherapy (my model for the psychotherapeutic treatment of chronic anxiety mixed with depression, repetitive self-defeating/self destructive behavior patterns, and ongoing overt family discord), it is often difficult for a therapist to help patients to quit focusing just on themselves and to start thinking about the interpersonal and family context in which their problems take place. If they have had previous therapy in which a therapist acted as if their problems existed solely within the confines of their own heads, the major switch in frame of reference may be particularly problematic for them.The psychoanalytic pioneer Alfred Adler devised a question that a therapist can pose to help a patient make this transition. He was the first to see the great value in asking patients the following: If somehow by magic the problem you have described were completely solved, what negative consequences might ensue? This question, or variations of it, have been adopted by several different psychotherapy treatment models, including family systems therapy, solution-oriented therapy (the “miracle question,” of DeShazer), and brief therapy (Gustafson’s Complex Secret of Brief Psychotherapy). In unified therapy, the question is designed to trace the adverse consequences within the patient’s family of origin that might occur should the patient stop self-destructive, self-defeating, or spoiling behavior patterns. To almost any problem a patient presents, there is a conventional solution that seems obvious - so obvious in fact that the therapist should assume that the patient has already thought of it. This is especially true if the therapists thinks of the solution almost immediately. If it that obvious, the patient has thought of it too, and has also no doubt been advised about it by several other people. It still amazes me how stupid some therapists think their patients must be to not have seen it.Presentation by the therapist of such a “solution” to a patient with a personality disorder invariably leads to a game of "Why don't you - yes but." The patient presents a series of lame excuses why they cannot employ the obvious solution, or why it will not work for them.Rather than do that, I ask a patient"If I had a magic wand and I could magically make this problem go away, what would be the downside?" Examples are: "If somehow you could get over your fear of asking nice women out, what additional problems would that create?" and "Everyone is probably advising you to tell your father that your career is none of his business. I wonder if something bad would happen if you did that?" If the patient is initially confused by the question, I might ask the patient to visualize having successfully overcome the problem and then ask, "What's wrong with this picture?" Alternatively, I may ask the patient directly who might be affected negatively if the patient were better adjusted.Readers of this blog can begin to change their own recurring maladaptive behavior by asking themselves this question. Ask yourself: “If I had a magic wand that allowed me to successfully solve my major problem, who in my family might have a negative reaction or be adversely affected?” If you try this, you obviously have to be honest with yourself and try not to be defensive, and think about the answer for a while. Do not let your mind drift off. The answer will reveal which family relationships you need to change, and if you are seeing a therapist, where your focus should be in your treatment.There are some answers you might think of which do not really answer the question. Do not let yourself stop yourself from problem solving with them. Examples of same: 1. "I'd just find some way to mess things up." The magic wand won't let you do that.2. "It would just affect me, and I'd be a nervous wreck!" The reason you would be nervous is because of the consequences to other people. What are those consequences?3. "I can't even imagine it." Really? You can imagine anything. You can picture yourself flapping your arms and flying. If you “cannot” picture something, that just means you are afraid to think about it. What is your fear? Be courageous and think about it anyway. It won’t kill you, I promise.4. "That would never happen." Remember, it's a magic wand, so it already has happened.To illustrate subtle variations of these non-answers: My patients sometimes tell me that the negative consequences of solving the problem would be an alteration or escalation of their self-destructive or self-defeating behavior. An example is "If I got up the nerve to ask a nice girl for a date, I would probably end up making a fool of myself over dinner." All this means is that the patient, if deprived of his or her usual ways of playing out a family role, would merely find another way to act it out. It avoids the question of why the patient is playing the role in the first place. I would counter with, "What would be the downside if you were able to have a totally successful relationship with a nice woman?"Another example of an unacceptable answer is, "If I started dating really nice women, I'd start picking at my skin until I bled". Again, what might be creating the anxiety that leads to this in the first place? In cases in which the negative reaction the patient fears comes primarily from a spouse or partner, and the patient seems to be avoiding an obvious solution to the couple’s problem, then I want to know about the downside of solving thatproblem. I would wonder who in the patient's family of origin might be negatively affected if the patient were somehow magically able to have a happy marriage. Sometimes the Adlerian question brings an immediate answer that sheds profound light on a patient’s family dilemma. One patient told her therapist about how she made herself miserable every day at work by constantly thinking up and worrying about catastrophic occurrences that could take place that day. (Of course none of them ever came to pass). She did this knowing full well that the scenarios she thought up and feared were extremely unlikely, so cognitive therapy would be useless in getting her to stop. The therapist instead asked her, “What would happen if you were able to stop yourself from doing that and enjoyed your work?” The patient’s immediate response was, “My mother would not know what to do with herself, and she would stop sending me money!”In asking yourself this question, it is helpful to understand what the real answer to the question might look like. These feared consequences should be plausible, probable and serious. For example, your mother might get seriously depressed and suicidal, or your parents might divorce. Sometimes my patients respond with the notion that they really do not care what happens to their families, and that their motivation for maladaptive behavior is really selfish. Unfortunately, there is an obvious logical contradiction between self-destructive behavior and selfishness. Some behaviors such as destructive rages or over-eating can be made to look gratifying if you don't think about them too much, but the experience of them, not to mention their consequences, is anything but. You are too intelligent to be unaware of this. The only "selfish" motive behind self-destructive behavior is your wish to avoid the anxiety associated with watching your family members suffer.Another counterproductive response is to flagelate yourself for being a patsy. I personally believe strongly that caring and concern are good things. Perhaps there is a better way to express them than sacrificing yourself on the family altar.