From symptom to symbol Language in psychotherapy

Fabio Ricardi ¹

1. Centro Berne Scuola di Specializzazione in Psicoterapia, Milan, Italy.

[email protected]

OPEN ACCESS

PUBLISHED: 28 February 2025

CITATION: Ricardi, F., 2025. From symptom to symbol. Language in psychotherapy. Medical Research Archives, [online] 13(2). https://doi.org/10.18103/mra.v13i2.6225

COPYRIGHT: © 2025 European Society of Medicine. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

DOI https://doi.org/10.18103/mra.v13i2.6225

ISSN 2375-1924

ABSTRACT

The effectiveness of psychotherapy is now recognised in the scientific literature. The article identifies the reasons for this effectiveness in the strength of the therapeutic alliance, in which therapist and patient work together towards a shared goal. This alliance on the other hand, it needs to be based on a common language. We study the characteristics of the two codes of human communication, symbolic and subsymbolic, and their possible synergy in a therapeutic relationship that achieves its goal.

Keywords

• psychotherapy
• therapeutic alliance
• symbolic communication
• subsymbolic communication

1. The challenge of psychotherapy

In this article I propose to analyse a central element in the success of psychotherapy, namely the language that the therapist and the patient use to communicate with each other (and that the patient uses to communicate with himself). Human communication, as we shall see better, is symbolic, albeit in different ways and at different levels, and therefore the language of psychotherapy, in order to be successful, must be able to move in this symbolic area. Since this subject, effective communication and in particular communication in psychotherapy, has already been dealt with for some time, I will refer to some scholars who have dealt with it (S. Freud, psychoanalytic literature, the pragmatics of human communication, E. Berne and W. Bucci) using their help to make, if possible, some personal contributions. Since my professional activity is psychotherapy, I will also refer to my clinical experience. In this part, the method of study will logically be the clinical method, i.e. listening to the patient’s narrative, observing his behaviour, and interpreting one and the other.

The premise of this investigation is the assertion that psychotherapy is an effective method of treatment, i.e. that it promotes in the patient a change in the direction that the patient and therapist propose. This thesis is now widely shared by scholars, after years of discussion, in which some researchers asserted the opposite, namely the futility of psychotherapeutic intervention (Eysenck, H.J., 1952), and thus stimulated a more accurate investigation of clinical cases, and meta-analyses of the research carried out. Today, an authoritative source such as the American Psychological Association (A.P.A.,2012) can commit itself to supporting precisely the therapeutic value of psychotherapy. Pharmacology is also effective in enabling the patient to overcome the symptoms from which he suffers, but psychotherapy, even if it requires a commitment of a certain length of time, has the advantage of greater stability in its results. The patient acquires a capacity for understanding and processing what were the sources of his suffering. And this capacity is no longer lost.

Once it has been established that psychotherapy is an effective healing tool, the question remains legitimate: how does psychotherapy cure?

We must not underestimate, I believe, the difficulty of what is at stake. How is it possible for a person to change long-held beliefs about himself, emotional and behavioural patterns that have often been habitual for years? And how is it possible for this to happen by virtue of the relationship with another person, the therapist; a relationship that can take up a lot of time, but is nonetheless based predominantly on verbal communication, the ‘talking cure’, as one of Freud’s early patients called it? I do not deny that there are also forms of psychotherapy that engage the body a great deal, nor do I want to forget that verbal communication is also, always, communication that exploits the expressive means of the body. It remains true that the fundamental element of psychotherapy is the relationship between two people. How is it that the relationship with another person is so important and transformative for what belongs to my life?

The most common answer emphasises the importance of the therapeutic alliance. For therapy to work, it is necessary that between therapist and patient that particular relationship is created, which has been given the name ‘alliance’, in which the therapist’s instructions are felt to be meaningful for him or her, and the therapist’s own person is felt to be authoritative, reliable and protective.

The theme of the therapeutic alliance came into focus after Freud’s research and reflections on the patient’s transference, and the analyst’s relative counter-transference. Freud indicated by transference the distortions to which the patient subjects the relationship with the therapist, not evaluating it in its reality, but transforming it on the basis of his own previous relational experiences, touched more or less deeply by the impact of the same neurosis. In the Frudian perspective, therefore, transference is seen as something that jeopardises the success of the therapy, but on the other hand makes present, in the hic et nunc of the therapeutic relationship, the heart of the problem from which the patient suffers, and thus allows its solution. Whilst the correct path, for the therapist, is the analysis of the transference, the risk is that of an immediate response, i.e. the counter-transference, in which the therapist also enacts, in communication with the patient, something that belongs to his past history and which he has not yet resolved adequately. Freud himself, however, acknowledged that not all the space of communication between patient and therapist is occupied by transference and countertransference, but he also affirmed the existence of an “irreprehensible transference” (Lingiardi, Gazzillo, 2014), that is, of a communicative modality in which the patient realistically sees the figure of the therapist, and the relationship with him. Starting from these analyses by Freud, in psychoanalytic literature (and also outside its confines) the concept of therapeutic alliance has come into focus, wanting to indicate that happy situation, and optimal for psychotherapy, in which patient and therapist work together in view of a common goal. This happy situation can be sought and realised.

Not only psychoanalysis, of course, has studied what happens in communication between human subjects. One of the most important contributions in this field was made by the Palo Alto School. One can see especially the ‘Pragmatics of Human Communication’ by Watzlavick, J.H. Beavin and D. Jackson. In pragmatics one studies, as the authors write, “the pragmatic (behavioural) effects of human communication” (ibid., p.7). The topic is important because communication structures the relationship between people, in ways that are functional but also often dysfunctional both to the clarity of the message and to the happiness and mental health itself of the people involved. In any case, while studying those fundamental characteristics that they call the ‘axioms of communication’, the authors of Pragmatics define two modes that are very close to the perspective followed by W. Bucci, and to which, as we shall see in a moment, I refer. “In human communication there are two entirely different possibilities of referring to objects (in the extended sense): either representing them with an image (as when drawing) or naming them.” (Pragmatics, cit.,p.52). Naming means deciding (a given community of men speaking the same language decides) that a certain set of sounds indicates a certain object; and between those sounds and the object there is actually no similarity. Analogical communication, on the other hand, is based on the similarity between my gesture, whether physical or verbal, and what I want to communicate (as a child does when, to indicate a dog, he says ‘woof’.) “Man is the only animal known to us that uses both analogical and numerical forms of communication” (Pragmatics, cit.p.55). It seems to me that, although she does not cite Pragmatica, Bucci begins by noting the difference between these two modules, in order to highlight the relationship that must nevertheless be established between them. Moreover, while Pragmatics is fundamentally concerned with the effects of communication on behaviour, the theory that Bucci calls the ‘multiple code’ delves into another essential aspect of human communication, that of being symbolic.

Before sharing W. Bucci’s analysis, I would like to focus on another study that highlighted two different forms in human communication. It is an article by a Freudian-trained psychiatrist, E. Berne, who went on to build a new theoretical and therapeutic orientation with Transactional Analysis. In this 1953 essay, ‘The Nature of Communication’, Berne devotes himself to a pioneering study: the comparison between computer communication and human communication. The point of view chosen by Berne (following in this the founder of cybernetics, N. Wiener) is the distinction between ‘information’ and ‘noise’. “The information carried by a precise message in the absence of noise is infinite. -writes Wiener – In the presence of noise, however, this amount of information is finite” (Wiener, 1948. cited by Berne1992, p.38). Information is what the designer wants the machine (the computer) to communicate. But there is a residue, something that the machine inevitably transmits even if it was not designed and is not related to the intended information. Perhaps this is no longer true of today’s computers, which are far more sophisticated than those Wiener referred to in 1948. But the model Berne uses is equally effective. Contrary to appearances, the noise is not an insignificant deviation: it ‘speaks’ to us about something, i.e. the internal state of the machine. And here the comparison with human communication, and in particular the communication between patient and therapist, becomes interesting. In fact, the patient wants to say certain things, perhaps many, but others he says without meaning to, with his posture, his gestures, with his tone of voice. All this, if we maintain the comparison with the machine, is “noise”; but, in this case, valuable noise, as it informs us about the “internal state” of the sender, i.e. of the patient who speaks. And the ‘internal state’ is what is of interest in psychotherapy, much more than explicit narratives. The psychotherapist must be a specialist in the interpretation of “noise”, seen as a message coming from the “internal state” of the person speaking to him.

To return to the therapeutic alliance, from which we started, we can say that this cooperation between patient and therapist, who manage to work together towards a common goal, is inaugurated and maintained by virtue of successful communication. A success that still leads us to reflect on the nature of language. Let us start from afar, and pause for a moment to analyse the essential characteristics of human language. A characteristic aspect of language – quoted from an essay that has the virtue of clarity and conciseness – is the presence of a set of symbols, i.e. a set of (acoustic) signals, the words, which refer to (mental) concepts, which in turn refer to entities in the real world”. (Fabbro, 2018,p.24). This entry into the world of signs is at the same time entry into the social world, because the meaning of these signs, i.e. their ability to point us to the real world, is shared with speakers of the same language. With a finite number of signs – the letters of the alphabets are around 20 or so – a virtually infinite range of combinations can be created. These combinations, the words, can then be combined with each other in the most varied ways, making the most complex constructions of the human mind expressible and communicable. One only has to follow a child’s learning of the mother tongue to realise how arduous this feat is: a feat that the child achieves in the first two years of life with admirable learning power.

The mind is not always open to this transition from the world of sensations and emotions to the world of symbols. Where there are psychological difficulties (let us content ourselves for the moment with this summary expression), one of the first manifestations is precisely the difficulty in elaborating a world of meanings appropriate to one’s own experience: the world of language.

2. Two codes for communicating

By naming things, language allows us to structure our experience, as well as put us in communication with others. But before the language of words, is there another modality that enables us to achieve, in a different form, the same goals? Among the scholars who have answered this question in the affirmative, the contribution of W. Bucci is, in my opinion, particularly important. (Bucci W. 1997) In short, his thesis is that, before symbolic language in the strict sense, man has constructed a ‘subsymbolic’ language. It is the language of emotions and of what we might call operative intelligence. The fact that, in the evolutionary course, this mode of communication comes before the language with which we speak and reason, does not detract from the fact that it is also constantly used in everyday life. Emotions are a complex phenomenon, involving the nervous system, lived experience and also somatic modifications. They are important messages for the subject, as they inform us about the quality of the relationship between us and the environment, and are also, as they are manifested through the body, an instrument of social communication. As for operational intelligence, not only do we use it for operations necessary to life, such as walking, running, keeping one’s balance, but also for operations typical of our living in a world of technology and machines. Just think of the intelligence needed (clearly non-verbal) to change lanes on the motorway at the right moment.

Human communication is built through the collaboration of these two codes. Collaboration, but also sometimes conflict. It is enough to think of the misunderstandings in interpersonal communication, often due to the incongruence between the message we send in the symbolic code, and that which, perhaps unconsciously, we send through the subsymbolic code, with non-verbal communication. What we have said allows us to state that the symptom is also a language. The symptom is, in general, the translation of a psychological discomfort. By symptom I mean, for example, the ruthless self-criticism and insensitivity to pleasure of the depressed person, or the need to repeat ritual behaviours, aimed at protecting against imaginary catastrophes, of the person suffering from obsessive compulsive disorder. We therefore find in the symptom a negative and unpleasant experience for the subject, and a more or less important limitation of his or her emotional, intellectual and operative capacities. The suffering experienced is what motivates recourse to psychotherapy. Consisting of emotions, behaviour, modes of thought that are in any case perceptible to others, even if at first sight often incomprehensible, the symptom is definitely communication, and communication within the subsymbolic code.

3. The hidden symbol

How is this experience that we call a symptom constructed? All psychotherapeutic orientations today agree in identifying two orders of causes for psychological distress: genetic and environmental. (NIMH, 2021) The environmental ones play a significant part, however, and such as to merit the attention that science and therapeutic practice have devoted to them since at least the 19th century. ‘Environmental’ essentially means ‘relational’. To recognise the environment as having a causal function is to recognise the importance of life events, and, specifically, of the person’s interpretation of life events, and particularly of the early years of life.

By ‘event’ I mean something that involves the person’s relationship with others, especially fundamental others, starting with parents or caregivers. By ‘interpretation’, of course, I do not mean an intellectual operation done at a desk, as when someone writes their autobiography, but the continuous reading of what happens, done while living. A reading that, made through emotions and intuitive intelligence, often takes place in an unconscious way.

I bring three clinical cases in this regard, and I add a clarification. I do not think that three clinical cases constitute a ‘demonstration’ of my theses. More modestly, I think I show that my reflections have a basis in experience, and not only in literature, however authoritative; and suggest that every psychotherapist can trace something similar in his or her own professional practice. To claim that what I have observed always occurs in successful psychotherapies would require a much richer collection of clinical cases.

One of my patients, a woman in her thirties, (we will call her Giulia) has an elderly father who recently suffered from some health problems. The daughter was very worried, and during a session she said this sentence: “If my father dies, I will be alone.” In terms of pure reality, the statement is not true: my patient would still have her mother, a sister, and even friends. But the dreaded death of her father would mean loneliness for her. That is, it would manifest for her something deeper than the factual reality: a dimension of loneliness that belongs to her inner world, and which her father’s disappearance would bring to light.

Another example belongs to a moment following the construction of the symptom, i.e. when its meaning is reconstructed in the course of therapy. A girl with anorexia problems (we will call her Alice), who entered therapy with great motivation and a remarkable capacity for self-analysis, summarised a moment in her story as follows:”. Then I said to myself: if I am thin, I will be perfect.” One understands in this way that extreme thinness, sought after through diets and calorie control, was not a value in itself, but insofar as it represented in physical terms the true value that could not be renounced: perfection. And consequently, it was something that, in the time of her illness, this girl could not do without.

I do not want to say that understanding this symbolisation coincided with recovery. But that the ability to read one’s symbols gave meaning and interest to the therapeutic journey, gradually allowing her to dismantle and go backwards through the mental and affective construction that had led her to the reduction of food, up to a situation of risk. And to gradually experience the possibility of other life options.

In another case, that of Viola, I was able to witness the entry into a symbolic and affective world, which left behind her an area of concrete, subsymbolic thinking, very similar to that of anorexia. For some months Viola had been subject to hypochondriac fantasies: she often felt short of breath and imagined she had this or that illness. She felt the passage of time and was afraid of growing old (actually, she was in her forties at the time of therapy). She sadly imagined her children growing up and leaving her alone. In reality there was one family member who was really leaving her alone: her father, who was suffering from an early form of Alzheimer’s, and was no longer the one her daughter knew. One evening we work on this theme, the affectionate care that Viola received from her father, and which from now on will no longer be there, at least in the ways that Viola knew. We see a link between this care and the care she gave, and is still giving, to her children, but which, at least in her fantasy, is coming to an end.

In the following week’s session Viola recounts having spent a few days in a mountain village that was a family holiday resort during her childhood, and walking one morning, alone, through a wood that her father had introduced her to. She realised that that forest represented her father and she let herself go into a long cry. And she felt that weeping as liberating.

Here too, analysing what happened, we find the recovery of the symbolic capacity (the wood is her father) and, at the same time, of the possibility of expressing pain, instead of translating it (in a subsymbolic way) into fantasies of aggression towards her own body. Should such fantasies reoccur, Viola holds the key to solving them. I emphasise: not the key provided by the therapist with an interpretation, but the key she has fabricated for herself, from the experience of therapy.

The clinical cases we have examined, those of Giulia, Alice and Viola, tell us that the symbol is implicit within the symptom. And this appears as paradoxical. The symptom is, in itself, a communication in the subsymbolic code. But, if we go to interpret it, and thus grasp its deeper meaning, we discover that the symptom is constructed by exploiting a series of relations between meanings that respond to a symbolicity different from that of spoken language. The latter, let us remember, is constructed in an apparently arbitrary way; there is no similarity between the sound of the word ‘dog’ and the animal that that word stands for. We enter the world of symbolism, digital and no longer analogical, by a sort of leap that intelligence makes at a certain point, and which is shared by an entire social group. We see instead that the symptom is constructed by a relationship of similarity between things or events that are otherwise different. In this way we are in a situation that brings us closer to the original etymology of the word ‘symbol’.

Symbol’, from ‘sun’ and ‘ballo’, i.e. ‘put together’ (in ancient Greek), indicated a personal object, such as a ring or a bracelet, that could connect with another person’s, and thus allowed for recognition, for establishing a relationship. An analogy is possible with the rings that even today, newlyweds generally exchange at the time of marriage. Extending the meaning, the symbol speaks of a relationship between objects or realities that are different, but at the same time connect in some aspect. If we pay some attention to how symbols are constructed and used, in common language and in the language of poetry (which is a privileged space for the symbol), we realise something important. It is not the pure similarity that gives rise to the vision of the symbol (after all, many things resemble others, but we do not necessarily pay attention to that), but the similarity plus our emotional or affective participation. In the clinical cases reported, there is certainly a link of meanings between death and loneliness (a link, this one, tending to be shared by every member of our culture.), And between perfection and thinness? In this case the connection is not there for all of us, but certainly in the mental universe of a person who is sliding towards anorexia. We may not share this connection, but for the person experiencing it, it is very real.

In any case, the two events – death and thinness – acquire symbolic value for the two people, and thus also a significant impact in their lives, thanks to the presence of a strong emotional dimension. And how can they, the protagonists of this experience, emerge from this to arrive at a vision of themselves that is more serene and open to the values of life? It is necessary to retrace the symbolic itinerary, in its cognitive and affective aspects: to retrace it in the strong meaning it had for her or him, and in the emotional participation that marked it. In this retracing there is also the implicit understanding that the link established by the symbol is not of unquestionable necessity. Things or events that are connected by the symbolic perspective could also exist without this connection. The presence of my subjectivity is necessary for this connection to be there. I can decide, at a certain moment in my life, to no longer recognise the link between these meanings, and to be, rather, open to different meanings. As for the two patients just mentioned, the first can accept her father’s strong emotional presence in her life, recognise the concrete possibility of death and make this awareness the basis for a different understanding of life values. The second must understand the genesis in her personal history of this need for perfection, and also understand that she can do without it. At this point the symbolic link between perfection and thinness also falls apart. As for Viola, in her weeping she has already accepted her father’s illness, and understood that his future absence did not mean taking away the value of all that she, Viola, was achieving in her own life.

The symbolic capacity that also acts in the construction of the symptom, I would like to stress, is not a purely cognitive ability, but is an orientation in which the mind elaborates a world of emotions, needs, expectations, and makes them representable in some way. Thus, it is for Giulia’s emotion of fear, as she realises how much she fears loneliness if her father were to leave her. In Viola’s case, the forest, with its reality unscathed by time, presents itself as a guarantee against the passing of human life, and makes it acceptable (and in this case the symbol, which takes the place of the symptom, already expresses its constructive efficacy.). In Alice’s case, thinness makes ‘perfection’ concrete and perceptible, an absolute ideal which, in her life, represents the answer to a deeper conflict.

4. Towards healing

It is reasonable to think that healing retraces, in the opposite direction, what happened in the genesis of the disorder and the symptom. If we think of psychotherapy, it is necessary that in the relationship between patient and therapist it becomes clear to both of them the pathway by which the events and emotions experienced translated into discomfort, and this, passing through often unconscious images, was translated into a symptom. Understanding this basic symbolism is not a purely intellectual procedure, but involves, first and foremost for the patient, something that, albeit with approximation, we can call energy. The construction of the symptom required great energy, and constituted for the patient’s life a new equilibrium, albeit a very costly one. Dismantling this balance, and seeking a new one, can easily lead to a feeling of emptiness. Having a companion on this difficult journey is certainly essential: that is why therapy is a journey for two. What is required of this travelling companion? In the perspective I have followed so far, great attention is asked of the other’s communicative modes, especially the way in which the subsymbolic code is mixed, sometimes coherently and sometimes not, with the symbolic code of speech. It is precisely in the subsymbolic code used, unintentionally, at a certain moment of the therapeutic session that one can pick up the traces of that basic symbolicity that has collaborated to construct the symptom. And thus, begin that path backwards that allows one to understand, and eventually abandon, the unhealthy interpretations of life events.

5. Conclusions

I would like to summarise the results of my research at this point. Human communication allows information to pass through signs. The first signs developed in human history (but also in the history of the individual) are based on the similarity between the sign and the object it is intended to indicate. At the same time, the sign makes manifest – i.e. perceptible to other subjects – something that belongs to the inner world of the person communicating. This mode of communication, which still lacks the explicit symbolism of spoken language, has also been called ‘subsymbolic’. Spoken language, which is the most specifically human language, is not based on similarity, but on an astonishing characteristic of speech (and of words connected according to certain rules, grammatical and syntactic), that of being able to indicate objects, of the external world and of the internal world. Human unhappiness – we are not speaking here of physical pain, but of that experience that we use to call psychic discomfort or suffering – is expressed first of all in the form of the ‘subsymbolic’ code, which is based on some similarity between the sign and the experience it is intended to signify. In this case, the subsymbolic code is as ‘private’ as ever, that is, typical of the person who experiences it, and only of him or her. Psychotherapy is the work of two people, who undertake to put the two codes into communication, to free the subsymbolic one from its privateness and to translate it into interpersonal communication. In this translation, the patient discovers a different possibility of dealing with the suffering that is included in the symptom. This different possibility can also be the discovery that suffering is no longer necessary. And this, evidently, is the best possible outcome for psychotherapy.

Conflict of Interest: None

Funding Statement: None.

Acknowledgements: I would like to thank my patients, who helped me reflect on the meaning of human distress.

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