A woman, who we shall call Caroline, contacted me three years ago and presented with anxiety and panic attacks which became unbearably intense when she tried to drive over high bridges. The woman worked as a recruiter and made over $100,000 a year. She was in her 50s, divorced and had two teenage children. She was born in the Caribbean where her parents still lived. Caroline said that her inability to drive over bridges was affecting her economically because she was taking Ubers to and from work. She had tried yoga, herbs and meditation but nothing was helping.
When patients come into therapy with a presenting problem, that is only the tip of the iceberg. Patients tell the therapist what they consider their primary concern. However, there are always issues that the patient does not consider which contribute to the presenting problem and are also issues in their own right. There is no one magic explanation as to why Caroline got anxiety when she drove over a bridge, because there is no such thing as “bridge anxiety.”
Caroline was a 50-year-old divorcee with two children who was concerned about her future financially and in terms of companionship. She did not have a supportive family and felt isolated. All of these concerns made Caroline anxious. Her anxiety also manifested itself in an irrational concern about cleanliness, and she could not return items to her kitchen cabinet without cleaning them twice every time.
Because Caroline felt desperate to meet someone, she would sleep with men on the first date. She thought that if she made them happy then she would get what she wanted. She rationalized this by saying that she liked sex and as an adult did not have to apologize, but this explanation did not pass the sniff test. Every time she slept with someone she became emotionally involved, and at a certain point the men would drop her. This happened repeatedly. She even traveled to islands and other states in order to try and meet someone new. She often put herself in unsafe situations. She would lend money to men and she would never get repaid.
As Caroline worked through the issues facing her she got control of them and started to see herself more clearly. She started understanding the complexity of her motivations. By copying the therapist’s objectivity, Caroline developed her observing ego. Whereas she once presented as a selfless person who wanted to please other people, she learned how this approach was designed to suit her own needs and was often a bad strategy because it allowed others to take advantage of her.
If a therapist only tries to help patients with their presenting problem they do them a disservice, because the presenting symptom can be replaced by “replacement symptoms.” The anxiety that caused the symptom goes underground and comes out to express itself another way. Anxiety does not disappear. It is part of the human condition and must be managed over a lifetime. Some ways of managing anxiety, called coping skills, are more adaptive than other ways of managing anxiety. Eating is a way that many people cope with anxiety but it is not as adaptive as exercise. If exercise becomes excessive then the extra time spent exercising becomes maladaptive.
Every symptom has meaning to the patient who suffers from the symptom, but the patient is usually unaware of the meaning, just as people are unaware of the meaning of their dreams. One of the goals of therapy is to help the patient learn what each symptom means to them. Symptoms do not have one meaning, they have many meanings, because human behavior is never determined by one motivation but by many motivations. This is called “over determinism.” Asking why a person does something is the wrong question. Instead, we ask, “What were the numerous, various even conflicting motivations that someone had for doing what they did.?”
For example, take the case of someone who overeats to the point that they become obese. It might look like this person is a glutton, a hedonist, a person with no self-control. This could be true. It might also be true that by eating so much the person is punishing themselves. Are they a glutton or a glutton for punishment? Both. This way of dealing with anxiety and personal conflicts is obviously not healthy, but since it is driven by emotions it cannot be easily stopped by an appeal to reason.
In order to understand the meanings of a symptom, you must understand the entire person. It took time to get to know Caroline and what the different parts of her life meant to her and how she put them together in her own individual way. Each person constructs their life differently, so the meanings that any particular symptom has to one person is unique to that person. There is no one meaning to any particular symptom or any particular dream. There are an infinite number of possibilities that can only be understood on a case-by-case basis. Therapy done properly is not formulaic. The therapist should always be “flying by the seat of his pants.” He can’t rely solely on prior knowledge or prior experience. He can use them to help him understand the patient, but he always must be listening for the unique meanings that each patient brings to their story. Every life story is new and unique, even with patients who share the same diagnosis.
Jonathan Bellin, LCSW. received his B.A.degree from Yeshiva University in 1989 and his MSW from Yeshiva University in 1993. He has a teletherapy practice where he sees patients 18 and older. He treats ADHD, depression, anxiety, Obsessive Compulsive Disorder (OCD), PTSD, trauma, and relationship issues. Jonathan studied psychotherapy at Harvard, the NY Freudian Society, the William Alanson White Institute, and worked at FEGS and JBFCS. He can be reached at [email protected].
