In this article
When someone goes to a doctor, the conversation opens with what do you have. When they come to me, it opens with what is happening to you. The difference looks small and is in fact two different assumptions about what a symptom is.
In the first case a symptom is a sign of a fault to be found and removed. In the second it is something that arose in your life for a reason — and that reason is often sensible, even when the consequence is unpleasant.
This piece is not an attack on the medical view. Both views are useful and both have a blind spot. What interests me is what happens when, instead of “let’s get rid of it”, we look at a symptom and ask “what is it doing”.
Two views of the same thing
Take insomnia, since it is common enough.
The medical view asks: how long has it lasted, what is your sleep hygiene like, is the difficulty falling asleep or staying asleep, is there a physical cause. The aim is to restore sleep. That is sensible and often successful.
The psychotherapeutic view asks something else: when did it start, what was happening in your life then, what is it you think about at three in the morning, and what would have to happen during the day so that it did not need chewing over at night.
Both views look at the same symptom. The first treats it as a fault, the second as a message about the system a person is living in. And it often turns out that insomnia is the only space in which someone has allowed themselves to think about what they may not think about by day.
What it means that a symptom does something
This is the most contentious part and worth saying carefully, because it is easily misread.
I am not claiming you choose a symptom, or that it brings you something you want. I am claiming something else: every persistent pattern has a function — it was once the best available solution, which is why it consolidated.
A panic attack is an alarm that learned to fire too early, because it once fired too late. Numbness is protection against feelings that were once too much. Perfectionism was an entirely reasonable strategy in a child loved only for achievement. Controlling food, in someone who controlled nothing else, was the one area where control worked.
In all these cases the symptom is not a sign that something is broken. It is a sign that something worked — then. The trouble is that it continued into circumstances where it no longer serves.
That changes the tone of the conversation. Instead of “how do we get rid of this”, the question becomes “what did this serve, and do you still need it today”. The first question, with persistent patterns, often ends in a fight with yourself. The second almost always opens something new.
Why removing a symptom is sometimes not enough
Medicine works on a simple rule: remove the cause and the symptom goes. With mental states the relationship is more complicated.
When a symptom carries a function, removing it leaves an empty place. It is a familiar observation in family therapy that when one symptom recedes, another appears in the same person or in another family member. That does not mean treating symptoms is wrong — it means it is incomplete when nobody addresses the function.
A practical example: an adolescent whose distress is the only thing still keeping their parents in conversation. If we remove the distress without anyone looking at what is happening between the parents, the system often finds another route. This is exactly why family therapy does not work with the “symptom bearer” but with the whole — I have written about this in family therapy is not a search for a culprit.
An important limit: this does not apply everywhere. In acute psychosis, severe depression or an eating disorder with medical risk, reducing the symptom is urgent and cannot wait for understanding. Searching for meaning during an acute crisis is a luxury a person affords once they are safe.
How this sounds in practice
Some questions I ask instead of “when did it start” — and what I am looking for with them.
“When is it absent?” Exceptions are the most telling information there is. A symptom present at all times is rare; most fluctuate. Where and with whom it dips tells more than the average.
“What would have to happen if this vanished tomorrow?” The answer often reveals what the symptom is currently preventing. “Then I’d probably have to say I’m leaving” is an answer that changes the entire conversation.
“Who in your life notices it most?” Symptoms tend to appear in relationships, not in empty space.
“What would change in the family if it were gone?” With adolescents and couples this question often opens the real subject.
None of these questions denies that someone is suffering. All of them shift attention from what they have to where it lives.
Where this view has its blind spot
Since I have been critical of the medical view, it is fair to say where my own approach fails.
Looking for meaning where there is none. Some conditions are largely biological, and a persistent search for symbolic meaning is a waste of time — sometimes worse, because it delays appropriate treatment.
The risk of blame. If a symptom does something, it is a short step to “so you wanted it”. That conclusion is wrong and cruel. Function is not intent.
Explanations are seductive. A good story about what a symptom serves is satisfying and not necessarily true. The test is always the same: has anything shifted in daily life.
Slowness. This route is slower than one that reduces the symptom directly. When someone can no longer wait, the faster route is the right one.
What this means for you
If something has troubled you for a long time and you have already tried to remove the symptom, it is worth asking differently once.
Not “how do I get rid of this”, but: when did it first appear, what was happening then, and what would have to change in my life if it were gone tomorrow.
The answer to the last question is often uncomfortable. That is usually where the work begins.
What to remember
A symptom is not always a fault in the system. It is often a solution that once worked and carried on too long.
That does not mean it should not be reduced — with severe states that is the first step. But it does mean that removing the sign is not always the end of the work, and that with persistent patterns the question “what did this serve” gets further than “how do I get rid of it”.
Sources
- Minuchin, S. (1974). Families and Family Therapy. Harvard University Press. Harvard UP
- Watzlawick, P., Weakland, J. & Fisch, R. (1974). Change: Principles of Problem Formation and Problem Resolution. Norton. Norton
- Carr, A. (2019). Family therapy and systemic interventions for child-focused problems. Journal of Family Therapy, 41(2), 153–213. Wiley
- Hayes, S. C., Strosahl, K. & Wilson, K. G. (2011). Acceptance and Commitment Therapy (2nd ed.). Guilford Press. Guilford
- Engel, G. L. (1977). The need for a new medical model: a challenge for biomedicine. Science, 196(4286), 129–136. PubMed
- Kirmayer, L. J. (2005). Culture, context and experience in psychiatric diagnosis. Psychopathology, 38(4), 192–196. PubMed
Try asking differently
Not "how do I get rid of this" but "what did this serve". If that question gets stuck, we are in the right place.
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