Symptom as message

Many people come to therapy because their day-to-day life has been disrupted by a symptom — a repeated behaviour, an intrusive thought, a reaction that feels out of proportion, or a difficulty they cannot quite account for.

The symptoms therapy works with are not medical symptoms. Rather than signs of illness or biochemical imbalance, a symptom is considered a message: a way of letting ourselves know that something is out of sync with us.

 

Medicine and therapy

We are familiar with medical symptoms — visible signs like rashes or fevers that point to an underlying physical condition.

Measles, for instance, announces itself through fever, cough, and rash: a clear causal chain. Medicine treats the underlying condition, and the symptoms resolve.

Therapy addresses a different class of symptom altogether — not of disease, but of psychological processes. Chief among these is repression.

 

Symptom as substitute

Repression operates beyond awareness, removing from consciousness thoughts, memories, or satisfactions that cannot be admitted — and replacing them with disguised substitutes.

A symptom, in this sense, is repression’s work made visible: a stand-in for what could not be directly expressed.

We can see this in everyday speech. When someone prefaces a remark with “I don’t wish to criticise you, but…”, the unsolicited denial is itself telling — simultaneously disowning and betraying what they cannot quite admit.

The subject is made present in the very act of being denied.

Unlike medical symptoms, the symptoms therapy encounters are protective formations — compromises between what presses for expression and what cannot be allowed. They tell us we have fallen out of sync with ourselves.

 

A portrait with the subject missing

An artwork by David Hockney offers a way into how therapy symptoms work.

Panama Hat emerged from a conversation between Hockney and his friend Henry Geldzahler, who was fundraising for the charity Phoenix House. Geldzahler recalls:

Hockney said, “Let me do a portrait of you” and I said “You really can’t because I am fund-raising for them. It would look a little funny.”

So Hockney said, “Well”, and just sat down… and in about an hour, he did my jacket, my hat, my pipe, and my iced coffee.

I like that picture because it’s a portrait of a subject with the subject missing.

The result — a substitute for what could not be represented directly — echoes how symptoms function.

The subject is present everywhere in the work: in the hat, the jacket, the pipe. And yet the subject is missing.

 

Symptom as nonsense

That repression involves substitution explains another feature of the symptoms therapy encounters: their apparent nonsense.

Some people feel compelled to check a door lock not once or twice, but repeatedly. Others find themselves erupting over what seems, to them and to others, like a triviality.

That these behaviours appear irrational is the inevitable consequence of repression: the real subject is missing or disguised, and what remains looks, from the outside, like it makes no sense.

It makes sense — but the sense is hidden.

 

When repression falters

Repression, in its ordinary operation, allows everyday life to proceed. The symptom becomes routine — second nature, even.

It is when repression falters, when the symptom grows too disruptive or too costly to maintain, that people often turn to therapy.

And sometimes, after beginning therapy, people are surprised to trace a symptom back further than they expected — to earlier moments, or entire chapters, of their lives that they had not thought to connect to their present difficulty.

The first task of therapy is not to eliminate the symptom but to approach it as something half-expressed and deeply personal — to give it a hearing, and begin to understand what it has been saying.

 

A final image

Hockney’s 1972 painting Chair and Shirt appears, at first glance, to be a simple still-life — two everyday objects, plainly rendered.

But the work is 183 by 183 centimetres: six feet square. The scale is unexpectedly monumental for so modest a subject.

If Panama Hat is a portrait with its subject missing, might Chair and Shirt carry the same logic? And if so — what is the missing subject here?

It is the kind of question a symptom asks too.

 

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Notes

The measles reference is used here as a familiar example of symptom logic in medicine, and is not intended as clinical commentary.

Henry Geldzahler recalls his conversation with Hockney in Art in America, February 1981.

For further reading on Hockney’s use of displacement and metonymy, see my, David Hockney Paintings, co-authored with Ulrich Luckhardt, Prestel (1994), chapter four.

For more on how therapy approaches specific symptoms, see the reading, Therapy for Phobias↗

Originally written June 2019, revised July 2026.