Why Two People with the Same Symptom May Need Completely Different Treatment

One person suffers from panic attacks. A second person presents with exactly the same symptom. Both describe heart palpitations, shortness of breath, a fear of dying, or a fear of losing control. From a symptom-based perspective, the two cases appear to belong to the same diagnostic category and, therefore, to require the same treatment.

Psychoanalytic thinking takes a fundamentally different approach.

For the psychoanalyst, the symptom is only the starting point of the investigation, not its conclusion. The fact that two people present with the same symptom does not mean that it arises from the same psychological processes, serves the same function, or belongs to the same personality organisation. On the contrary, behind an apparently identical clinical picture there may exist two entirely different inner worlds.

This distinction represents one of the fundamental differences between psychoanalytic understanding and approaches that are organised primarily around the diagnosis of symptoms.

The Symptom Is Not the Illness

In everyday life, we often mistake the symptom for the problem itself. If someone suffers from insomnia, we assume that insomnia is the problem. If someone experiences anxiety, we believe that anxiety itself is the disorder. If a person presents with obsessive thoughts or panic attacks, we tend to regard these symptoms as the psychiatric illness itself.

Psychoanalysis offers a different perspective.

The symptom is not the psychological disorder. Rather, it is an expression of the way the mind attempts to preserve its equilibrium in the face of internal conflicts, anxiety, or developmental difficulties. In other words, a symptom is not merely something that causes suffering; it is also an imperfect solution to a deeper psychological problem.

This means that two identical symptoms may serve entirely different psychological functions.

In one individual, panic attacks may reflect an intense conflict between the wish for autonomy and the fear of losing the love of significant others. In another, they may be related to fragmentation anxiety that threatens the very cohesion of the personality. Although the external manifestation appears almost identical, the underlying psychological reality differs profoundly.

The psychoanalyst therefore does not stop at describing the symptom. Instead, the symptom is understood within the broader economy of the individual's psychological life.

The Same Diagnosis Does Not Mean the Same Person

Diagnostic categories are valuable tools for communication among mental health professionals. They allow certain clinical characteristics to be described and facilitate scientific research.

However, no diagnosis can adequately capture the complexity of a human personality.

Two individuals who meet exactly the same diagnostic criteria may differ in virtually every psychologically meaningful way. They may love differently, fear differently, defend themselves against emotional pain differently, and possess entirely different capacities for self-reflection, symbolisation, and psychological growth.

Psychoanalytic work therefore does not begin with the question, "What is the diagnosis?" It begins with a different question:

"How is the psychological world of this unique individual organised?"

The answer to this question is what ultimately guides treatment.

Personality Organisation Determines Therapeutic Strategy

Contemporary psychoanalytic theory, particularly Object Relations Theory, directs its primary attention not merely to symptoms but to the overall organisation of the personality.

The therapist seeks to understand how the individual experiences the self and others, the quality of internal object relations, the predominant defence mechanisms, the capacity for affect regulation, the stability of identity, and the person's relationship with reality.

These dimensions are far more important in treatment planning than the simple description of symptoms.

A person with a highly integrated personality organisation may be able to make productive use of free association, tolerate interpretations, and use the therapeutic relationship as a vehicle for profound psychological change.

Another individual with a far more fragile personality organisation may initially require a treatment focused on stabilisation, strengthening the capacity for thinking, containing overwhelming emotions, and establishing a secure therapeutic framework.

It is therefore evident that the same therapeutic technique would not be appropriate for both individuals.

The Same Symptom May Serve Different Psychological Functions

Psychoanalytic thinking regards every symptom as serving a specific function within the mind.

A phobia may protect against an unconscious conflict.

An obsession may function as a defence against aggression or guilt.

Depression may reflect unresolved mourning, a harsh superego, narcissistic collapse, or profound disturbances in early object relations.

Even when two symptoms share the same diagnostic label, their psychological meaning may be entirely different.

For this reason, psychoanalytic treatment does not attempt to apply predetermined protocols. Every treatment is constructed around the unique psychological reality of the individual rather than around the name of the symptom.

Why the Same Intervention May Help One Person but Harm Another

Treatment is not a technique mechanically applied to a symptom. It is an encounter between two minds in which every intervention acquires meaning only in relation to the particular individual receiving it.

An interpretation that helps one patient achieve deeper self-understanding may be premature for another. If the second patient does not yet possess sufficient psychological cohesion, the very same interpretation may increase anxiety, reinforce defensive processes, or even contribute to psychological disorganisation.

This does not mean that the interpretation was incorrect in its content. It means that it was not appropriate for that individual's level of psychological functioning at that particular moment.

Psychoanalytic technique is therefore determined not only by what is psychologically accurate but also by what the patient is capable of assimilating creatively.

Treatment Follows the Personality, Not the Symptom

Contemporary psychoanalytic theory, particularly through the work of Otto Kernberg, makes it clear that the central clinical question is not "What symptom does this person have?" but rather "At what level is this person's personality organised?"

An individual with a neurotic personality organisation typically possesses a stable sense of identity, relatively mature defence mechanisms, and good reality testing. Such a person may benefit from deep interpretations of unconscious conflicts and use the therapeutic relationship to work through internal contradictions.

By contrast, an individual with a borderline personality organisation may struggle to maintain stable representations of both self and others. Their psychological life is often characterised by intense fluctuations between idealisation and devaluation, difficulties in affect regulation, and reliance on more primitive defence mechanisms.

In such cases, the initial therapeutic goal is not the immediate interpretation of unconscious conflicts but the strengthening of psychological cohesion, the gradual integration of fragmented self and object representations, and the development of the capacity to think about emotions rather than enact them.

In even more fragile levels of personality organisation, where reality testing itself may be compromised, therapeutic priorities change even further. Establishing a stable, containing, and psychologically safe therapeutic environment becomes the prerequisite for any deeper interpretative work.

Thus, the same panic attack may require entirely different therapeutic approaches—not because the symptom has changed, but because the person experiencing it is fundamentally different.

Developmental History Matters More Than the Symptom List

Psychoanalysis is always interested in developmental history.

How did the child experience relationships with caregivers?

Was emotional availability present, or did inconsistency dominate?

How were dependency, aggression, frustration, and the need for comfort responded to?

How were the earliest representations of self and significant others formed?

The answers to these questions allow the psychoanalyst to understand not only the origins of symptoms but also the developmental processes through which the entire personality became organised.

Two individuals may both suffer from depression, yet in one person it may primarily represent unresolved mourning, while in another it reflects a chronic experience of inner emptiness rooted in severe disturbances of early object relations.

The diagnostic label "depression" alone is insufficient to describe these profoundly different psychological realities.

It Is Not the Symptom That Is Treated, but the Person

Perhaps the most important contribution of psychoanalysis is its shift in focus from eliminating symptoms to understanding the individual who produces them.

This does not mean that symptoms are ignored or that relief from psychological suffering is considered unimportant. On the contrary, symptom relief is an essential therapeutic objective.

However, psychoanalysis maintains that enduring psychological change occurs when the mental processes that generated the symptom are transformed, rather than when only the symptom's outward manifestations are suppressed.

As the quality of internal object relations changes, as symbolisation develops, as defence mechanisms become more mature, and as individuals acquire greater psychological freedom, symptoms often diminish naturally as a consequence of this deeper reorganisation of the personality.

Conclusion

The fact that two people present with the same symptom does not mean that they suffer from the same psychological condition or require the same treatment.

For psychoanalysis, every symptom acquires meaning only when understood within the broader context of the individual's personality organisation, developmental history, internal object relations, defensive structure, and unique way of experiencing the self and others.

This is why psychoanalytic treatment is not based on standardised protocols, nor does it apply identical techniques to every person who receives the same diagnosis.

Instead, every treatment is a unique therapeutic process designed around the uniqueness of the individual. In psychoanalysis, the object of treatment is not the symptom itself, but the whole personality that lies behind it.