The Institutional Defence Against Meaning: Why Clinics Abandon Symbolic Work

As a clinical psychologist, I believe the greatest threat to therapy today isn’t underfunding or burnout—although of course that is never too far away - it’s the silent evacuation of meaning from our work. The shift has been subtle but pervasive. Behaviour is now dissected, categorised, measured. Rituals are labelled, tracked, targeted. Yet the emotional core—what I would call the symbolic heart of the work—is often nowhere to be found.

What Do I Mean by Symbolic Work?

Symbolic work refers to the clinical stance of listening beneath surface behaviour to the deeper emotional and representational life of the young person. It is the practice of tracking how inner psychic states—conflict, fear, longing, rage—become transformed into symptom, language, ritual, or silence.

It’s the difference between hearing a hand-washing ritual as a contamination fear versus hearing it as a child’s desperate attempt to cleanse a ‘bad self.’ It’s the ability to notice when a refusal to speak is not just defiance but a collapsed symbolising function—a psyche that no longer trusts language to carry pain.

Symbolic work asks:

• What is this compulsion trying to say?

• What unbearable state is being managed through this repetition?

• What does the young person need to represent—but cannot yet find the words for?

This way of working is rooted in psychoanalytic traditions—Klein, Bion, Segal, Meltzer—but is not confined to them. It is a way of thinking and being with, not a protocol. Symbolic work treats behaviour as language. It treats symptoms as attempts at meaning, not just signs of malfunction.

Why Institutions Defend Against Symbolic Thinking

Clinical systems, like psyches, fear what they cannot control. Symbolic meaning is inherently unstable—it moves, resists measurement, and speaks of pain that no intervention can neatly erase. For an underfunded clinic, a metric-obsessed commissioner, or a stretched-out team, this is intolerable.

So the organisation defends.

But instead of repression or denial, it uses:

• Over-reliance on metrics (quantifying what should be felt)

• Standardisation of language (flattening idiosyncratic thought)

• Taskification of therapy (replacing listening with action plans)

• Pathologising resistance (treating symbolic unreadiness as non-compliance)

These are not just operational habits—they are psychic defences in institutional form. They protect against the anxiety of uncertainty, the mourning of what can’t be fixed, and the ethical demands of genuine human contact.

The Human Cost

When symbolic work is stripped away:

• The adolescent’s rituals become “target behaviours,” not communication attempts.

• The parent’s confusion is given handouts, not understanding.

• The clinician becomes a technician, not a witness.

And most tragically:

The child’s psyche is never truly met.

We risk becoming part of the original trauma—the failure to be understood—by reenacting it in the consulting room, under the guise of efficiency.

Reclaiming Symbolic Work Is a Political Act

To listen symbolically is not a romantic ideal. It is an act of resistance.

It refuses the flattening of human experience into bullet points. It demands that therapists be trained not just to deliver treatment, but to hold psychic life with depth, humility, and tolerance for ambiguity. It insists that we attend not just to what is done, but to what it means.

In a system addicted to doing, symbolic work insists on being.

What I’m Doing About It

As a clinical psychologist, I’ve aligned myself with a group of professionals who are trying to bring symbolic listening back to the heart of therapy for children and adolescents with OCD and intrusive thoughts. We’ve built symbolic tools to help clinicians name the invisible, teaching modules to restore emotional depth, and language frameworks to make sense of projective processes without jargon.

This is not a rebellion against evidence-based practice.

It is a return to meaning-based practice.

To Listen Is to Risk

Symbolic work is hard.

It demands something of us.

It brings us close to things we would rather not know—about our patients, our institutions, and ourselves.

But without it, therapy becomes a ritual of its own:

One that soothes the system, but leaves the child alone.

I believe that in every act of symbolic listening, we reclaim something urgent—not just for our patients, but for ourselves as clinicians.

Because without meaning, there is no healing.

There is only procedure.