Letter to the Editor

DEAR SIR,

With reference to M. F. Hoyt's informative paper on 'Secrets in Psychotherapy …' (1978, 5, 231–241) I notice, with regret, the absence of pertinent observations concerning the frequency and significance of secrecy in patients with hidden bodily anomalies and concealed physical defectiveness. Though the author alludes to this in his well-chosen motto, Isak Dinesen's statement 'a secret is an ugly thing, like a hidden physical defect', I miss in the article any further elaboration of Dinesen's pointed comparison. Nor are references from the analytic literature pertaining to such 'secret' physical afflictions adduced in the author's text and bibliography.

I relate, for example, to P. Blos's (1960) report on a patient with cryptorchism and the 'mysterious exclusion' of this malformation through years of treatment. I also refer to my own analytic communications with regard to patients with congenital or early acquired hidden deformities (1956), (1965), their guilt-ridden secrecy about them, and the 'nodal' involvement, as I called it, of such patients in their emotional experiences and fantasies which centred to a large extent on their outwardly non-visible physical defects. The feelings of shame and guilt derived therefrom, the marked tendencies towards secrecy about and the sometimes bizarre fantasies connected with them, require our full attention as analysts. The fantasies about the hidden defect, usually kept secret, are often florid, expansive and aggressive; they influence primarily the body- and self-image and require not only the analyst's understanding, but also minute analytic unravelling. One of my patients, suffering from a covert facial disfigurement, saw herself—secretly—as a veritable 'monster' in appearance, behaviour and fantasy (1975).

Freud's famous dictum (1923) that 'the ego is first and foremost a bodily ego' is here fully applicable.

In summing up, I wish to state that in every properly conducted psychoana