The First Interview with a Psychiatrist

and the Unconscious Psychology of All Interviews

Charles Berg

• Publisher: Routledge
• Year: 2021
• Print ISBN:
  9781032170657
• eBook ISBN:
  9781000518634
• Topic: Psicología
• Subtopic: Salud mental en psicología

Originally published in 1955, the blurb read: 'Again in this book the author expounds his main thesis – perhaps the main thesis of all modern psychiatry – namely that our conscious pre-occupations, thoughts and behaviour are merely the products or "symptoms" of a process that is going on within us (basically a physiological process) of which we are totally unconscious. Although we are at pains to conceal from ourselves and others, and even vehemently to deny, the nature and the very existence of this fundamental unconscious process, it is nevertheless the determinant of all that is us, biologically, psychologically and sociologically. In the author's own words: "It is the force behind all activity, all life. It exists unseen in the most apparently superficial human relationship, even in the interview – as this book will show. It alone can give us the meaning of what we do and feel."

The theoretical section of the book deals with the interviewer and the unconscious forces which determine the effects and the therapeutic results of the interview. The longer practical section demonstrates, by abundant examples from clinical material and by complete documentaries of actual psychiatric interviews, that it is unconscious forces which determine the patient's symptomatic picture, his behaviour, his attitude to life, and above all his emotional relationship to the psychiatrist – and indeed to everyone he meets in every personal contact.

The elucidation of this process should be of the utmost interest and of the utmost practical value to each of us in our every contact, superficial or deep, with every human being whom we meet in the course of our lives.

The book will appeal to a wide public. Although it demonstrates the deepest and most worthwhile aspect of modern psychology and psychiatry, it avoids technical jargon and is written in a cheerful, lively and lucid style, easily assimilable by everybody.'

Today it can be read and enjoyed in its historical context.

This book is a re-issue originally published in 1955. The language used is a reflection of its era and no offence is meant by the Publishers to any reader by this re-publication.

PARTS III TO V: PRACTICE

PART THREE The Interviewed FROM THEORY TO PRACTICE

CHAPTER XIV A Case of Blushing

the first case I shall describe is a particularly simple one. It will be seen that although the interview proceeded with apparent smoothness, technical difficulties, especially as regards therapy, were practically insuperable at first. Had this patient been capable of insight without treatment, it may be that he could not have developed his particular symptoms.

He was a single young man, very tense and awkward, whose complaint can be put under the familiar category of blushing, though in his case blushing had developed a very peculiar and interesting form of expression.

In spite of his embarrassment, or because of it, he lost no time in plunging into his story: ‘I have always been very nervous and self-conscious, but the trouble has been getting worse for some months. It used to be blushing, very severe, getting all hot and flushed, breaking into a sweat; but, lately (you may think it very stupid), it has developed into something quite intolerable, quite impossible—I have thought of throwing up my job, and clearing out of the country; I just can’t stand it going on while I am at work. Before this last thing developed there was no crazy idea; I was just nervous, inclined to blush, very uncomfortable; but now it is this thing that I can’t stand.’

He paused. I sat there looking blank and stupid. At length I asked, ‘What is it?’

‘What is it?’ He expostulated, ‘Can’t you see what it is? It is my ear burning and going red. I thought of throwing up my work, because it’s worse in the office. All the time at work I am in a continual fear of it happening . . .’

Analyst: ‘Perhaps that’s what brings it on?’

‘Yes, yes, you are right, I suppose it is the fear of it happening that actually brings it on.’

As, at this point, he was a little dumb, I asked another question. He replied: ‘Yes, there is a girl at the office. She sits opposite me. She’s a peculiar girl, only about nineteen, but I know she is continually looking at me. I don’t feel too good about it, because I realize that this red ear may come on at any moment, and I shall feel awful, and want to chuck up the whole job, and get out. I think she realizes that my ear sticks out too much at this spot, and that it is abnormal. She gives me the impression that she is looking at it. All the time I feel that the ear-burning is going to come on, and I shall be noticed; she will notice it. I find it difficult to go to work on account of this fear. I breathe a sigh of relief when the day is over.’

The reader may, by this time, have suspected that, while this was the current, conscious form of this young man’s morbid anxiety and worry, it had had a history, an antecedent, which was now less acutely conscious, perhaps partly repressed. This antecedent was the familiar, protracted pubertal and post-pubertal period of masturbation with worry, undue fear of it, and unsuccessful attempts to suppress it.

It is not always a good thing to ask a patient to detail his masturbation phantasy at any time in analysis, particularly at a first interview, but somehow it emerged in this instance. It was a pretty normal one, namely that of unclothing in imagination some member of the opposite sex. He had never actually experienced any sexual intercourse. The matters of special psychological interest were, one, that for some years masturbation had in his opinion been excessive, two, that a development of his phantasy had been the unclothing of, and imaginary intercourse with, the particular girl who sat opposite him at the office, and, three, most relevant of all, the fact that he had, in recent months, succeeded, by dint of great struggle and effort, in relatively suppressing these thoughts and activities; with the result, he said, that they now occurred only once in two or three weeks. Asked for the reason of this he said simply: ‘The reason I have not done it more often is that I don’t think I should.’

The psychopathology of his symptom can, therefore, be outlined as follows. His sexual instincts, at puberty and after puberty, had met with the familiar frustrations, inhibitions and attempts at repression. A conflict had been set up between instinct on the one hand, and super-ego (‘I don’t think I should’), plus ego, on the other hand, with the result that sexual tendencies had been suppressed, and, to some extent, repressed. The girl who sits opposite him at work acts as a stimulus to both sides of this semi-repressed conflict. On the one hand, she stands for the imaginary gratification, and, on the other hand, more consciously, she stands for the reproving super-ego, prohibiting any such thoughts, creating feelings of guilt at having indulged in them, and causing consequent anxiety, suppressed anger and discomfort. The unconscious repressed guilt with its attendant threats of punishment, and unconscious castration anxiety, need not here be stressed, except to remind us that the anxiety at least breaks through repression and emerges into consciousness as a symptom. The effect of all this is that tumescence, sexual or genital tumescence, is effectively inhibited. He is not now conscious of any feelings of sexuality towards the girl. He is conscious only of the opposite, namely of anxiety and discomfort.

The tendency to tumescence which, in the absence of conflict, would have been experienced genitally, is strong enough to have escaped from repression by the familiar mechanism of displacement. Previously, in its first displacement, it expressed itself in his symptom of blushing, his face ‘hot, flushed and sweating.’ There is probably also a reaction of anger at frustration, lending a physiological basis to the humerous expression, ‘was my face red!’ At the same time, this symptom implemented the exposure and the punishment which his super-ego would inflict upon him for the guilty tumescence. With the further development of this illness, the tumescence has found a more specific phallic symbol for its expression and for his exposure, namely, his ear.

This case, though very obvious and superficial, may be of some interest as representing in a rather more severe form than usual the very familiar, almost universal, mechanisms of shyness and blushing.

I should add that, in this patient’s case, morbidity went a little deeper, and was rather more severe, than our discussion hitherto reveals. It transpired that the part of his projecting outer ear, or pinna, on which his guilty and discomforting thoughts were concentrated, was the little protuberance in front of the aperture, called the tragus. He had what might almost be called ‘ideas of reference’ associated with this. He actually half-believed the following phantastic story.

He said: ‘Some months ago I had an accident when mountaineering. I fell and rolled down what was almost a precipice. I do not know if the sticking out of this part of my ear was the result of the fall, but I have noticed it only subsequent to the fall.’ He was facing me at the time, and I pointed out to him that his other ear was exactly the same, quite symmetrical. He said: ‘Yes, I know they are exactly the same on both sides,’ rather impatiently, as though this fact were an unnecessary interference with the phantasy or delusion which he wished to maintain in reference to his left ear only. It was this ear which was nearer the girl who sat almost, but not quite, opposite him at the office; it was this ear only which was in the habit of becoming red and burning. He went on to tell me how various people had pointed out to him the prominence of this part of his ear, or at least ‘indicated’ that they had noticed it. He said: ‘I have only to look in the mirror now, and it makes me feel abnormal and ashamed.’ It is possible that the opening or ‘ear-hole’, immediately behind the tragus, made this visible part of his anatomy more accurately symbolical of the secret part which shame must conceal.

I do not think that it is a very far cry from the shame, from the feeling of abnormality now concentrated upon his ear, or this particular part of his ear, to the equivalent feelings of shame and abnormality which obsessed him during the early years of his masturbatory compulsion and conflict. However, the tendency to such ideas as these later ones, puts a graver aspect to the case. It suggests a slightly schizoid element, with a leaning towards paranoid ideas of reference. The rest of his psychopathology might be regarded as psychoneurotic, but this latter aspect suggests the admixture of a psychotic trend.

However, I am inclined to say that, in the absence of a family history of any important mental illness, in the absence of any marked infantile neurosis, and any previous mental breakdown, the prognosis in this case is probably quite good. Many of us pass through not only psychoneurotic but even tentative, mild, or borderline psychotic trends, and develop away from them rather than into them.

From the point of view of technique at a first interview, one may say that the confession of all these things to me, particularly the spontaneous confession of a good deal of his sexual life, indicates the lifting of some resistances, and would tend to initiate the development of some transference. In so far as he is rather more the schizoid than the hysterical type, that initial transference will be small. Nevertheless, it may prove the starting point towards a relationship which would have enabled me to help him, had the opportunity presented itself. I venture to think that had I attempted interpretation of his symptom, such for instance as telling him, this particular repressed young man, that the symptom meant nothing more or less than that he was automatically using his ear as a phallic symbol (and thereby playing into the hands of his castrating superego and ego), all I would have achieved is a checking of the transference tendency to me, and, perhaps, through me, to any subsequent psychotherapist. At least I think I avoided increasing his resistances.

I am sorry to say that circumstances (my time-table) were such that I had to transfer him elsewhere for treatment; but I think we can have hopes of a great deal of amelioration, particularly when his sexual life achieves its expression in more normal, egosyntonic ways.

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Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Original Title Page
• Original Copyright Page
• Introduction
• Table of contents
• PARTS I AND II: THEORY
• PARTS III TO V: PRACTICE