Dr. Plakun: It’s both a form of treatment and a theory of mind and development. The treatment involves the exploration of the unconscious meaning of symptoms and behaviors. The idea is that many of our patients’—and our own—personality traits and behaviors are governed by unconscious forces. The goal is to “break the code” of the choreographed symptoms and behaviors, bringing their meaning into awareness where they can be reflected on, put into perspective, and brought under conscious control. The theory encourages us to always be curious about the meaning of symptoms, and this curiosity can come in handy whether you are doing therapy or psychopharmacology.
TCPR: How is this helpful for a psychopharmacologist?
Dr. Plakun: In many ways, but I’ll give you an example of a person I worked with some years ago who showed a lot of resistance around my prescribing suggestions. She would refuse meds, she would sometimes take mini-overdoses; it was quite a struggle. When I learned her story of early experiences being sexually abused in ways that involved oral rape by a relative, it began to make sense that she didn’t want me to be in charge of what went into her mouth. We then paid more attention to the meaning aspect of the relationship, focusing on issues like the inevitable mistrust and worry about repetition of any kind of oral penetration, and as we worked this through, the struggles around prescribing lessened.
TCPR: That’s looking at the meaning of a behavior—what about meanings of symptoms? How does psychoanalysis view these?
Dr. Plakun: While we often tend to view symptoms as problems, in the psychoanalytic view symptoms may look like problems, but they are also actually solutions. They aren’t very good solutions, and hopefully we can help patients discover better ones. A term that’s often used in analytic jargon is “compromise formation.” A patient’s symptoms are a compromise effort to solve a problem. If our patients’ problems were just problems, they would be easy to solve. For example, consider a borderline patient who cuts himself repeatedly—if the cutting were just a problem, the patient would stop it, solving the problem. But it is also a solution. Cutting might represent the punishment that he feels he deserves, or perhaps he is struggling with not knowing who he is and feeling emotionally numb, and finds that when he cuts at least he feels something, even though it’s pain. And it isn’t for us to tell them the meaning. It is for us to be in a listening stance that allows us to learn the meaning—which our patient may know—or we may need to discover it together. So paying attention to what problem is being solved by a symptom is useful. In addition, paying attention to what they might lose if they were to lose the symptoms can also be important.
TCPR: Why would a patient not want to lose a symptom?
Dr. Plakun: Years ago, a woman came to Riggs with intractable psychotic depression, and no amount of medication would touch it: She kept hearing the voices. Now, if you talked to her you got the story—which was that the voices were of her dead child, her only child. And if she were to lose those voices, she would lose that dead child forever. When she could use her psychodynamic therapy to help her grieve the loss of her child, she was better able to respond to medications.
TCPR: Any other examples of how symptoms may have hidden meanings?
Dr. Plakun: Another common example is anxiety. Anxiety is two things: both a symptom and a signal. As a symptom, we might try to reduce or eliminate it. As a signal, though, anxiety is like a “check engine” warning light. We can try to ignore or cover up the light and drive on, or we can try to understand what is causing it—because it may signal important trouble that is out of our awareness.