Secrets

A main task of psychoanalytic treatment is uncovering and helping patients work through unconscious thoughts, fantasies, ideas, and feelings. These unconscious processes may be termed secrets from the conscious self. The main focus of this commentary, though, is on another kind of secret—i.e., secrets of which the patient is aware. The patient's attitude toward the secret, allusions to it, reasons for maintaining and/or divulging it, the way it comes up in treatment, its content and unconscious meaning, all provide meaningful clues to her or his level of psychological development, defenses, quality of object relations and conflicts.

Creating an atmosphere conducive to the patient's sharing secrets, understanding and dealing with resistances to this process, and embarking with her or him on an explorative voyage to discover the significance of secrets in relation to her or his level of psychological development and her or his conflicts are major treatment tasks.

Freud wrote that if the analyst demonstrates a sincere concern for the patient, works through resistances, and “avoids making certain mistakes,” a therapeutic relation will be formed. “Avoids making certain mistakes” is a key phrase. The following is an illustration of an underemphasized area where mistakes will undermine the patient's trust in the therapist and adversely affect treatment.

Mrs. I., an upper-middle-class lady, paid her monthly therapy bill in cash. Upon being asked why she chose to pay in cash, she indicated that she thought it would be preferred. It became clear that this method of payment represented both the need to test the therapist and to do something nice for her. Mrs. I. felt that if she paid in cash, the therapist would not have to report the income and therefore would not pay taxes on it. This would be a secret between the therapist and her. Had the therapist accepted the patient's mode of payment and neglected to explore the meaning, the patient would have a concrete reason to feel she