"Secrets in Psychotherapy"

DEAR SIR,

The recent letter by Niederland (1979) regarding my earlier paper on 'Secrets in Psychotherapy …' (Hoyt, 1978) merits further discussion. His main point, that I did not elaborate on the relationship of physical anomolies and defects to the development of secrets, is well taken. Therapists certainly need to be attuned to such possibilities, and may find valuable clues in taking a patient's medical and surgical history. Such information may be withheld, of course, as part of the patient's sense of their 'secret self' being damaged or defective. In such instances, one may still become aware of the patient's concerns, perhaps by their reports of behaviour outside therapy or by directly observing peculiar non-verbal actions within the transference relationship. For example, I recently noticed that a woman patient would remove her coat but than hold it across her lap and torso as we spoke. Upon inquiry, she revealed having several years ago undergone a double mastectomy, about which she had never spoken to anyone. Much of her feelings of shame and inadequacy were related to this unresolved stress event, material that needed to be brought into the open before it could be worked through.

Other patients may boldly exhibit their 'secret' physical defects in reaction formation. The reasons for such 'frank' counter-secrecy may be many and multidetermined: aggressively wanting to shock (turning passive into active); testing the therapist to see if he can cope with such material without shunning the patient; seeking validation and wanting sympathy; attempting to ward off discussion by 'getting it over with'; and so on. Especial tact is required here. What is usually most therapeutic is to acknowledge the patient's trauma and to demonstrate through one's interest in its meanings to the whole person that such 'secrets' can be accepted, understood, and ultimately mastered. The importance of helping patients work through secret material pertaining to physical los