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How Psychoanalysis Works
Eric M. Plakun, MD
Associate medical director, director of admissions at the Austen Riggs Center in Stockbridge, MA
Dr. Plakun has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
TCPR: Dr. Plakun, what would you say is the essence of psychoanalysis?
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.
TCPR: Can you give us an example?
Dr. Plakun: I once saw a woman who developed a bridge phobia after the death of her father. During our sessions, I learned that in childhood her relationship with her mother was distant, but she was closer to dad—who was more loving but could also be quite belittling and demeaning. In speaking about her phobia, she said that she had a terror of being swept over the side of a bridge while crossing it, and she felt a knot in her stomach when crossing bridges. When I asked if she’d ever felt that kind of knot in her stomach before, she recalled a childhood episode when she had climbed a steep and exposed fire tower with her father one windy day. It had been scary going up, but the prospect of descending was utterly terrifying. She asked father to hold her hand, but he refused, went down alone, and told her she would have to find her own way down. She had felt the same terrifying knot in her stomach as she descended very slowly. Father made fun of her timidity from the bottom. She had felt humiliated, enraged at “her father,” and abandoned by him.
TCPR: And what was the connection between her father’s death many years later and the onset of the bridge phobia?
Dr. Plakun: Her bridge phobia replicated the fire tower experience. She had felt abandoned by her father when she was descending the fire tower, and later her father’s death felt on some level like another abandonment, reawakening the old fears of vulnerability and of being swept away and falling.
TCPR: It is an interesting orientation to treating patients. In a more psychopharm-oriented practice, when a symptom is not responding, we tend to look for just the right combination of meds. But you’re saying we shouldn’t forget the value of digging a bit deeper into the meaning of symptoms.
Dr. Plakun: Yes. For example, let’s take the issue of treatment resistant depression. We all have such patients, and the question is “why is this patient treatment resistant?” There are certainly those who don’t take the medication, and then there are those who do not respond to medication they are taking. It turns out that among these non-responders, a large number have a history of early adversity and a lot of comorbidity. In the one large study, Skodol and colleagues found that comorbid personality disorders, especially borderline personality disorder, “robustly predicts the persistence” of major depressive disorder (Skodol AE et al, American Journal of Psychiatry 2011;168(3):257–264). So the practical tip is that if you have a patient with treatment resistant depression, don’t think only about the next medication to try, think about the impact of early adversity, and think about the contributions of comorbidity, especially comorbid personality disorders.
TCPR: How do we sensitively assess for early adversity?
Dr. Plakun: You don’t do it with a DSM checklist of symptoms. You do it by listening to the patient’s life narrative in a way that follows the affect. Typically, I start by asking about the events leading up to the problem that brought the patient in, what is usually called the history of present illness. But then I go back to their early childhood. “How were things? What was your mother like? What was your father like? What were your siblings like? How were you treated? Did anything go wrong? Were you bullied? Were you harmed in any way?” But I don’t pepper them with questions; I try to hear the story and follow the affect. So if you hear that their mother died when they were young, you say, “That must have been awful,” and you hear more about it. This kind of engagement is also part of building the therapeutic alliance—it shows you are with the patient in their experience. And it is crucial in finding therapeutic stories, which can be very helpful.
TCPR: What do you mean by a therapeutic story?
Dr. Plakun: Therapeutic stories are episodes from a life history that illustrate a powerful, often recurrent theme in a patient’s life They can be useful metaphors for a patient’s struggles. For example, I saw a patient in her forties who had been stuck in a pattern of treatment resistant depression for 10 years. In learning about her life, she told a moving story of having fallen into a cesspool as a young child, and nearly drowning in a difficult struggle to get out. Later, after a series of important relationship and work losses as an adult, she became depressed in a way that was refractory to treatment. It was quite useful for us to conceptualize her current plight in a way linked to the therapeutic story of the cesspool. She had once again fallen into one, and there was no one around who seemed able to help her get out—me included. We did a lot of work about her wish to be rescued, her anger at my limitations, and, ultimately, her own ability to find and use her own resources to reclaim her life.
TCPR: Thank you, Dr. Plakun.
General PsychiatryDr. 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.
TCPR: Can you give us an example?
Dr. Plakun: I once saw a woman who developed a bridge phobia after the death of her father. During our sessions, I learned that in childhood her relationship with her mother was distant, but she was closer to dad—who was more loving but could also be quite belittling and demeaning. In speaking about her phobia, she said that she had a terror of being swept over the side of a bridge while crossing it, and she felt a knot in her stomach when crossing bridges. When I asked if she’d ever felt that kind of knot in her stomach before, she recalled a childhood episode when she had climbed a steep and exposed fire tower with her father one windy day. It had been scary going up, but the prospect of descending was utterly terrifying. She asked father to hold her hand, but he refused, went down alone, and told her she would have to find her own way down. She had felt the same terrifying knot in her stomach as she descended very slowly. Father made fun of her timidity from the bottom. She had felt humiliated, enraged at “her father,” and abandoned by him.
TCPR: And what was the connection between her father’s death many years later and the onset of the bridge phobia?
Dr. Plakun: Her bridge phobia replicated the fire tower experience. She had felt abandoned by her father when she was descending the fire tower, and later her father’s death felt on some level like another abandonment, reawakening the old fears of vulnerability and of being swept away and falling.
TCPR: It is an interesting orientation to treating patients. In a more psychopharm-oriented practice, when a symptom is not responding, we tend to look for just the right combination of meds. But you’re saying we shouldn’t forget the value of digging a bit deeper into the meaning of symptoms.
Dr. Plakun: Yes. For example, let’s take the issue of treatment resistant depression. We all have such patients, and the question is “why is this patient treatment resistant?” There are certainly those who don’t take the medication, and then there are those who do not respond to medication they are taking. It turns out that among these non-responders, a large number have a history of early adversity and a lot of comorbidity. In the one large study, Skodol and colleagues found that comorbid personality disorders, especially borderline personality disorder, “robustly predicts the persistence” of major depressive disorder (Skodol AE et al, American Journal of Psychiatry 2011;168(3):257–264). So the practical tip is that if you have a patient with treatment resistant depression, don’t think only about the next medication to try, think about the impact of early adversity, and think about the contributions of comorbidity, especially comorbid personality disorders.
TCPR: How do we sensitively assess for early adversity?
Dr. Plakun: You don’t do it with a DSM checklist of symptoms. You do it by listening to the patient’s life narrative in a way that follows the affect. Typically, I start by asking about the events leading up to the problem that brought the patient in, what is usually called the history of present illness. But then I go back to their early childhood. “How were things? What was your mother like? What was your father like? What were your siblings like? How were you treated? Did anything go wrong? Were you bullied? Were you harmed in any way?” But I don’t pepper them with questions; I try to hear the story and follow the affect. So if you hear that their mother died when they were young, you say, “That must have been awful,” and you hear more about it. This kind of engagement is also part of building the therapeutic alliance—it shows you are with the patient in their experience. And it is crucial in finding therapeutic stories, which can be very helpful.
TCPR: What do you mean by a therapeutic story?
Dr. Plakun: Therapeutic stories are episodes from a life history that illustrate a powerful, often recurrent theme in a patient’s life They can be useful metaphors for a patient’s struggles. For example, I saw a patient in her forties who had been stuck in a pattern of treatment resistant depression for 10 years. In learning about her life, she told a moving story of having fallen into a cesspool as a young child, and nearly drowning in a difficult struggle to get out. Later, after a series of important relationship and work losses as an adult, she became depressed in a way that was refractory to treatment. It was quite useful for us to conceptualize her current plight in a way linked to the therapeutic story of the cesspool. She had once again fallen into one, and there was no one around who seemed able to help her get out—me included. We did a lot of work about her wish to be rescued, her anger at my limitations, and, ultimately, her own ability to find and use her own resources to reclaim her life.
TCPR: Thank you, Dr. Plakun.
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