“Symptom coherence” is how we refer to the view that there always exists a well-defined, cogent set of personal themes and purposes that necessitate a symptom—which is why the person produces it. The moment there no longer exists any purpose requiring a symptom, the person stops producing it. This view informed the development of a clinical methodology called Depth-Oriented Brief Therapy, which is shaped by assuming symptom coherence.

Carmen was 35 and happily married, but she experienced intense panic attacks every day or two. She described a recent panic episode she had while waiting for her husband to come home from work. When he was a few minutes late, she began imagining a terrible car crash and went into escalating panic.

Using a panic attack treatment technique we call “symptom deprivation,” I guided Carmen to reimagine the moments when she noticed her husband was late, but now without any accompanying panic. The goal wasn’t to counteract her panic response. Rather, it was to show that if panic was in some way compellingly necessary, then being without it would likely yield a consequence so dire that it would be worth going into panic to avoid it.

Carmen was silent for a time, and then said, “I know it sounds strange, but I start to feel scared over not having the panic.”

I then assigned her some panic attack treatment as homework. “When you notice you’re starting to have a panic attack,” I said, “that’s now your signal to see, just for a moment, if you can glimpse what you’d experience if you didn’t have panic.”

In the next session, Carmen reported she did the panic attack treatment homework one evening when her husband was late and her panic began. . She said it was now clearer to her why not having a panic attack was scary. “If I don’t worry that he’ll crash,” she told me, “it means I believe nothing bad will ever happen to us—and having that belief will make bad things happen! I really feel that if I suffer, it keeps anything bad from happening.”

She then described certain metaphysical rules of suffering that she hadn’t known were a powerful subjective reality for her. She felt that her family lived under a weekly quota of suffering, and she could spare her husband an auto crash by suffering intensely herself, thus meeting the quota.

Carmen had become conscious of the emotional truth of the symptom as a direct experience, not just a cognitive insight. Her initial thought that panic was something that happened mysteriously to her—like a traumatic memory—had been replaced by a clear recognition of her own purposeful agency in producing it.

Accepting the realness of Carmen’s world of meaning just as it was, I named the possibilities contained in her newly discovered constructs. “You can switch to a different type of suffering,” I said, “or you could deeply reconsider your beliefs and find whether they remain real to you. Because if they don’t, you won’t have to keep suffering to keep everyone safe.”

Carmen calmly informed me that the idea of changing her beliefs had no traction whatsoever for her, so the only alternative for her panic attack treatment was to find a different type of suffering.

The following week, Carmen told me she’d had no panic attacks for several days and hadn’t yet decided upon a different suffering to adopt. I suggested she keep on with that project. In the next session, she reported that she’d had no panic attacks for two weeks, and was still considering alternate ways to suffer.

Carmen was now in a process of dismantling the basis of her panic attacks, despite her earlier statement that the basis was so real to her that it couldn’t be changed. Here we glimpse the operation of one of Depth-Oriented Brief Therapy’s guiding principles: People are able to change a construct they experience having, but aren’t able to change one they don’t know they’re having.

Bruce Ecker

Bruce Ecker, MA, LMFT, is codirector of the Coherence Psychology Institute, co-originator of Coherence Therapy, and coauthor of Unlocking Emotional Brain and Depth Oriented Brief Therapy.