Shirah Vollmer MD

The Musings of Dr. Vollmer

The Formation of A Symptom

Posted by Dr. Vollmer on November 13, 2013


The patient experiences a stomachache. The physician is challenged to determine the pathophysiology, what is behind the stomach-ache on a biological level. The stomach-ache serves as a clue that there is a problem with the gastrointestinal tract. We, physicians, would not say that his diagnosis is “stomach-ache, ” but rather we would say that we are searching for the diagnosis, given his symptom of gastrointestinal distress. So, too, when a patient complains of “never succeeding at anything,” we do not say he is “depressed” but rather we, psychoanalysts, look for the underlying cause of his under achievement. The patient knows what he suffers from now, but he does not see what led up to his despair, in the same way that a patient with a tummy ache cannot do an upper GI to see his internal physiology. The symptom is the clue for deeper exploration, and as such, no conclusions can be quickly reached. “This analysis is going nowhere,” Luisa, sixty-one says, “there is no progress,” she continues to say in a defiant manner. “So, the analysis replicates other parts of your life in which you feel you are underachieving,” I say, highlighting how the theme of her existence is that she has potential, but she never lives up to it. As our work deepens, Luisa begins to see that her mother was threatened by Luisa’s academic success, and so to protect her mother from feeling inferior, Luisa unconsciously always held back living up to her potential, with the result that Luisa felt confused by her lack to effort and determination. Luisa was inhibited, self-imposed now, but discouraged at a young age, from excelling at school, and thereby opening doors which were closed to her mom. All these years later, Luisa continues the pattern of knowing she has potential, but then not making use of that potential to better her life. That pattern continues in our psychotherapy where she is constantly frustrated that she is not getting more “out of it”. Understanding and explaining her frustration is my job. I do not share her sense of limitation, but I understand why she needs to experience our therapy that way. Therein lies our work. Like the stomach-ache, until we can come to an understanding of the etiology, we cannot begin to know the right way to treat it. Stomachaches are not limited by twelve sessions, and neither should “psychaches”.

6 Responses to “The Formation of A Symptom”

  1. Jon said

    Symptoms lead to a diagnosis via an understanding of the causes of those symptoms. The desired treatments address the underlying malady, not just the symptoms themselves. Luisa’s experience of seeing the treatment as symptomatic of the troubles is wonderfully and sadly self-referential. Fortunately, in this fictional case, the astute therapist can provide the necessary insights.

  2. Shelly said

    On the one hand, it’s exciting to find out the source of Luisa’s psychological pain. On the other hand, though, it is scary for me to think that we can always look back and blame the parent for a child’s psychological scars. I realize that I do that myself, in my own life, so that I am not immune either. But I am a mother and am certain that no matter what I do, my children will do the same–one day they will all blame their issues and problems on my parenting style. How can we prevent hurting our children, even unwittingly?

    • I think we need to explore this issue of “blame the parents” as opposed to understanding what one is missing. A patient can understand without blame, with the notion that the parents did the best they could, but with that, there were deficiencies. Understanding goes a long way towards self-compassion, whereas blame keeps one in the victim mode. Thanks.

  3. Eleanor said

    On a personal note, years ago during my many years in analysis with a very astute psychiatrist/child/adult psychoanalyst my parents were never ever “blamed”. They were seen as human beings who made mistakes and I had to understand and learn from those mistakes and move on…. To blame my parents would have only increased the guilt I already had to deal with. I ended up seeing and understanding my parents as deeply human with their own struggles from their past experiences.

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