Case 18: Body Consciousness in Exhibitionism through Somatic Imagery

Aside from exhibitionism, the patient—a 28-year-old single painter—appeared to have no other major psychological problems. His past behaviour indicated that he had considerable difficulty in relating to women. He denied himself the release of sexual tension through masturbation—rather, when such feelings reached a peak, he impulsively exposed himself to women. Although he had experienced sexual intercourse on one occasion, he recalled feeling quite ashamed about this. In fact, he distinctly remembered imagining that someone was in the room watching the sexual act. When questioned about this, he indicated that the observer might be God who was there to punish him for having sex outside marriage. 

During interviews, marked resistance was encountered in discussing body attitudes. It was learned that he had doubts about the adequacy of his sexual functioning including fears of being sterile. His sexual fantasies involved situations where he and a woman would undress for mutual exhibition. However, at no time was sexual imagery in consciousness permitted to involve mental scenes of genital interaction between his body and that of a woman. Related to this, his past family background was characterized by a puritanical home situation and marked sexual restraint. 

<Level B>Method of Projective Testing 

SIS was conducted in the presence of a second investigator who observed the patient’s general reaction to the test situation. The study was conducted under two conditions. The first simply involved administering the anatomical pictures to the patient in a manner analogous to that employed with the TAT. The second concerned the modification of the individual’s consciousness using rapid acting intravenous barbiturate sedation. This was administered in enough dose to experimentally induce a state of psychic relaxation to control anxiety thereby reducing the patient’s inhibitions in mentally processing the somatic images stimulated by the pictures. 

Prior to viewing the pictures, the patient was given the following instructions: ‘I have here a series of pictures that I am going to show you one at a time. As you look at each one, tell me everything that comes to mind. Although different things are seen by various people, I am particularly interested in what it reminds you of in viewing it. Remember that there is a lot of time’. 

To obtain accurate records, both interviews were tape recorded and later transcribed for analysis. 

<Level B>Descriptions of the Pictures and Projective Responses Related by the Patient 

In this report, the results will be reviewed in terms of those which were most immediately relevant for evaluating the patient’s ability to mentally process sexual imagery. 

Urogenital Card (VIII)  

It may be observed that this picture presents visual input which facilitates the evaluation of a male patient’s propensity to permit phallic material to register in consciousness. Although statistical parameters are not yet available, our research group with this anatomical picture series has compiled extensive clinical experience. It has been found that in this picture, virtually all patients perceive anatomical content. A common response involves first responding to the upper configuration as ‘kidneys’ and then perceiving the lower areas as ‘bladder and penis’. 

Remarkably enough, the patient when shown this picture simply responded, ‘It looks like a couple of potato sacks’. Judging from his non-verbal behaviour in inspecting the anatomical ‘inkblot’, the observer considered that this non-anatomical response represented the only imagery that registered in consciousness. However, it must be acknowledged that it is, of course, impossible to exclude the possibility that the patient saw the sexual content but elected to not report it. 

Under the drug-induced hypnotic state the patient responded as follows 

‘That looks like a couple of men … a couple of men’s heads … there’s an eye (black mark on left kidney shaped object) … they’ve got no hair … and this is their noses down here…. I don’t know what that thing could be (lower area depicting bladder and penis) … it looks like another person off in the distance because it is smaller than these two … another person’s head with something on his head … and these two guys are standing here talking … they could easily be a couple of potatoes or a couple of people … (patient inverts card) … it still looks like two potatoes regardless of the way you hold it.’ 

It may be observed that the relationship between the pictorial reality (i.e., urogenital system) and the patient’s response pattern to this picture was highly remote. It is suggested that the patient’s imagery was much more dreamlike because the drug had released psychological inhibitions. 

Judging from the patient’s response, it may be inferred that the picture’s connotations more strongly impinged upon the consciousness than in the non-drugged state. Thus, the imagery was stated to resemble the facial area of ‘a couple of men’. However, this interpretation is complicated by the fact that previous research has shown that under barbiturate sedation, body consciousness tends to focus on the head (Cassell and Hemingway 1970). Consequently, it must be recognized that a partial determinant of his response could have been a drug-induced artefact. 

Next, one might consider the analogy between the projective response to the lower area—which depicts, in a covert fashion, the bladder and penis—as ‘a man with a mask over his eyes’, and his apparent failure to ‘see’ what is represented in that aspect of the picture. It is suggested that at some level of consciousness there was psychic awareness that the visual input provoked anxiety. In this sense the ‘mask’ may be interpreted to symbolize the patient’s reluctance to ‘see’ the phallic imagery impinging upon consciousness. Lastly, attention might be directed to the response ‘candlestick with a light burning at the top’. It is of interest that when the therapist later asked the patient to associate to this word, he responded as follows: ‘light bulb … darkness … stars … moon … lamp … funny shaped lamp like Aladdin’s lamp’. It is tempting to interpret the fact that you rub the last object to obtain magical effects, as symbolically reflecting the patient’s masturbation fantasies and unresolved sexual tensions. 

The last part of the response sequence indicates the re-emergence of non-anatomical content in awareness. Again, it appears that the patient failed to consciously recognize the phallic material inherent in the picture. 

After showing all the pictures to the patient in the drugged state, certain cards were presented for a third time. The urogenital card was the first of these. This phase of the case study was designed to have the therapist work with the patient until the phallic material inherent in the picture registered in consciousness. The patient’s anxiety in this situation was constantly evaluated and maintained within a range normally employed in desensitization behaviour therapy techniques. 

When this card was presented to the patient, the therapist introduced the anatomical content at a higher level of awareness with the following comment: ‘You said that this picture has to do with “potato sacks” or ”men”’. Now, let’s suppose that it has to do with body: What do you see?’ With this suggestion, the patient’s anxiety level increased, and he became noticeably perplexed. After a long pause, during which the phallic content more strongly impinged upon his consciousness, he asked the question ‘male or female?’ He was then informed that it was whatever he saw in the picture. After another long pause, during which he appeared to become even more anxious, the patient reported, ‘that looks like a man’s penis … and that looks like his testicles … and that’s all that I can see’. 

This deviated from previously observed responses in our research unit. Instead of initially referring to the upper areas as ‘kidneys’, and then subsequently perceiving the other areas in the male urogenital system, he first responded to the lower areas as ‘penis’. However, more unusual is his response ‘testicles’. Thus, he substituted more anxiety laden somatic images in consciousness over anatomical content more clearly depicted in the picture. 

In a retest examination, six months later, he responded as follows: 

‘It looks like two red things … like potatoes … it could be the shape of a person’s head … the black spot looks like an eye … the coloured part hanging down looks like a stem or foot joining these together.’ 

After having previously perceived the sexual material inherent in this picture, it is remarkable that six months later he once again failed to report seeing anatomy. Eventually, he was reminded of the anatomical content. In this instance, he projected the following pathological anatomy response: 

‘It’s a man’s penis but it has a funny shape the way it hangs down … it is swollen and there is a big lump on it … it doesn’t hang straight down … it looks like the after-effects of sexual intercourse … it’s aching and has syphilis or something … the testicles look swollen too.’ 

This may be interpreted to represent a direct projection of his hypochondriacal concerns about the effects of sexual intercourse. 

Male Figure Card (X)  

This picture clearly depicts the outline of a man’s body. It permits the patient to project responses related to the hands, the feet, the pelvic area, the limbs, the ribs and the lungs. Initially, viewing this picture the patient appeared to be markedly inhibited in that he only reported the following: ‘It resembles the shape of a man … but he doesn’t have a head’. Since normally male subjects do not comment on the missing head, this aspect of the response seemed worthy of note. It may be postulated to reflect an upward displacement of his concern about losing his penis. 

Under sedation, he responded as follows: 

‘This looks like the shape of a man … two arms … and that’s his neck … and he’s still got no head. That’s his two legs … and that could be his ribs … it looks as though somebody’s holding his hand around him because I see three fingers. And this thing … well, that looks like two potato sacks … joined together and tied at the top. They’re narrow at the top and they’re wide at the bottom … they’re tied together. That’s an owl or something (referring to the pelvic area) an owl or a … bird … or a bat, something like that … with … with wings anyway. These little pointed things look … they’re … horns on an owl … a horn owl.’ 

Once again it is evident that the sedative-induced hypnotic state was characterized by richer flow of visual images and verbal output. In the opening phase of the response sequence there was further evidence of the patient’s concern over the figure’s ‘missing head’. Next, it may be observed that the imagery stimulated by the rib-like structures in the picture had a bizarre and threatening connotation, in that ‘somebody’s holding his hand around’ the man in the picture. Remarkably enough, the areas, which are normally stated to represent ‘lungs’, are seen as ‘potato sacks’. Thus, to complicate the interpretation, there is evidence not just of perceptual inhibition of phallic imagery but other organ images as well. 

Lastly, attention might be directed to his response to the pelvic area in the figure. Since the symbolism is most interesting, the interview will be reported in detail. 

Patient (P): ‘That’s an owl or something … an owl or a bird or a bat … something like that with wings … anyway … these little pointed things look like they’re horns on an owl … a horn owl’. 

Therapist (T): ‘Suppose that it all had to do with one man. What do you see now?’ 

P: ‘Well, that could be a belt buckle on his pants or anything.’ 

T:   ‘What else could it be?’ 

P:    (Long pause) ‘I don’t know … can’t think of anything else.’ 

T:    ‘You seem to think of that an awful lot. What is that?’ 

P:    ‘I don’t know. I can’t figure out what it could possibly be … what part of a man that represented … (patient shifts focus of attention from the pelvic area to the lungs) … this looks like the insides … but … that there … I can’t figure out what that could be … can’t figure out why the insides would be that low down … it’s down below his waist or something … it just doesn’t seem as though it’s not normal because he is something different than other men … something that’s there and is not supposed to be there and that’s why I can’t figure out what it is.’ 

T:    ‘If it’s below his waist, what is it likely to be?’ 

P:    ‘Well, it could be his belly, but I guess it’s kind of big.’ 

T:    ‘Anything else it could be?’ 

P:    ‘No … I’m afraid, I can’t.’ 

In this aspect of the interview, the patient finally correctly identified the red areas as ‘internal tissue’, although he never labelled them as ‘lungs’. However, at no time did the imagery relate to the male genitalia stimulated by viewing the pelvic area of the figure register in consciousness. Yet, it is suggested that it strongly impinged upon awareness in that he projected concern about his own sexual organs as indicated by the response ‘it’s not normal, etc.’ 

This picture was represented to the patient for a third time after his seeing phallic material in the urogenital card had influenced his perceptual set. The dialogue between the patient and therapist is as follows: 

T: ‘Is there anything different that you see in this one now?’ 

P: ‘No, I can still see the body of a man.’ 

T: ‘Which body part would be represented here?’ (Pointing to the pelvic area) 

P: ‘Well, it’s that part of the man … in that shape I cannot say what it could be.’ 

T: ‘What kind of shape would it looks better?’ 

P: (Pause with no response). 

T: ‘Suppose that it was the shape of a candlestick, what would that make you think of?’ 

P: ‘Well, there are a number of things that I could name off for a candlestick’ [pause]. 

T: ‘Suppose I told you that the part here is the same as in this picture (pointing to the urogenital card) in representation, what would you think of it?’ 

P: ‘This sure looks like a man … he’s going to the bathroom or something … that looks like a penis’ (patient’s anxiety level high). 

T: ‘You seemed to have a lot of difficulty thinking that this is a penis. The other thing that you said was that the guy had something wrong with him’ … ‘Is that what you think about yourself?’ 

P: ‘Yes, that’s right.’ 

T: ‘There’s nothing wrong with you.’ 

P: ‘I still think that I do … I don’t know why.’ 

This aspect of the interview shows how this research technique may be used to stimulate somatic imagery more in the context of a relationship having potentially therapeutic as well as diagnostic implications. Under sedation, phallic imagery was activated in the patient’s unconsciousness. There was a great deal of resistance in bringing this into full awareness and considerable concomitant anxiety. However, in the state of relaxation induced by the drug, the therapist was able to interpret to the patient his psychopathologic body attitudes and partially desensitize the focal somatic anxiety. Of course, it is difficult to estimate the relative effects of visual input from the picture as opposed to verbal cues from the interviewer – in finally introducing the phallic imagery into conscious awareness. 

Six months later, in a retest situation, he responded as follows: 

‘That looks like the outline of a man … there are two arms and two legs and a neck … there is no head though … the red part … I don’t know … could be the intestines or some part of the body such as the heart or something.’ This response again avoids reference to the phallic aspects of the figure. It is also of interest that the patient readily recognized the anatomical implications of the internal lung-like structures. However, this visual input was not processed in a normative fashion as ‘lungs’ but consistent with his regression to an oral theme perceived as ‘intestines’. 

Human Figures Card (III)  

This picture presents line configurations, which may be seen to represent human figures. The bodies are close and share the same ‘body buffer zone’ (Horowitz, Donald, and Lois 1964). Normally, they are a man (left) and a woman (right) interacting in some way like dancing. The red areas represent ‘hearts’, which are often stated to symbolize their ‘love’. Normally, a few subjects give non-anatomical responses such as ‘lights’ or ‘red balls’. 

The patient’s initial response was unremarkable in that he saw the picture as representing ‘a couple of go-go dancers’ with the red depicting ‘apples’. However, under drugged condition, much more clinically relevant material emerged. He responded as follows: 

‘That looks like a couple of go-go dancers or something … this guy (left) looks as though he has a knife in his hand and she has got something too but I don’t know what it is … it looks to me as though they are going to cut those things in half … they are some kind of food or something … maybe that’s his hand hanging out there … they found a couple of apples … he’s going to cut one in half and give her one and himself take one.’ 

The fact that the patient perceived the male dancer as having a knife in his hand suggests that the theme represents a direct projection of castration anxiety and/or hostility towards women. There is also evidence of regression to an oral rather than sexual level of interaction. It also might be noted that when the patient’s therapist heard this response, the following question was asked: ‘What does cut an apple in half and giving it to her make you think of?’ In response, the patient identified with the picture in a regressive fashion stating, ‘Well, he likes her … I used to do that when I was a boy’. 

In the retest situation six months later, his response was quite different: 

‘There are two people … two pairs of legs and an arm … the red dots could be apples.’ 

When asked the sex of the figures, he reported that they were two ‘men’. Further, each of the two parts in between reminded him of a ‘penis’. The one on the left man was seen to be ‘long and erect’ and the right one as ‘short and soft’. When asked what they were doing, he stated they were ‘standing there comparing sizes’. 

In interpreting this response, it is pertinent to note that in the interim since originally tested, the patient had for the first time in his life become involved on one occasion in exhibitionistic behaviour and genital manipulation with a known homosexual. It is evident that the imagery stimulated in consciousness by this picture is much in line with this deviant behaviour. 

Female Figure Card (VII) 

This card was designed to evaluate the extent to which a female patient assimilates the feminine aspects of her body image into a gestalt. For the male patient, it appraises his ability to recognize and mentally process sexually evocative material related to a woman’s body. 

It presents two main aspects. The one of primary significance concerns the humanoid lower configuration consisting of two lines depicting the outline of the body, the hand and feet. There is a red area between these included to elicit responses related to stomach or genitalia. The upper red area denotes the mouth, and the black, the hair or, if the picture is seen as a man, a moustache. The second aspects refers to the top red object. It presents additional anatomical material relating either to the head area or the heart. Normally, this picture is stated to represent ‘a dancing woman’ with the upper object being ‘an apple’. Thus, a mature response involves assimilating the two lines, which are separated in terms of the right and left axes of the body into a gestalt, and then assigning feminine sexual identification to the figure. 

In viewing this picture, the patient responded to the upper configuration in the normal fashion, seeing it as ‘an apple’. However, consistent with his history of aversion to women, he simply saw the lower lines as representing ‘two animals’. The black area was stated to represent ‘a little black seal’. His failure to resolve the line configurations into a gestalt representing the body of a woman provided further evidence of his anxiety in mentally processing sexual imagery. The perceptual defence utilized in this instance, involved a breakdown of gestalt mechanisms of perception. 

The patient’s response sequence in the retest situation is of considerable interest because it shows how the separate components are eventually resolved into a gestalt as the patient’s anxiety is controlled. His associations to the picture were as follows. 

‘This is a fish or an apple or bell or something (top red object) … and it’s a big fish and he’s swimming after … these are a couple of snakes (lower lines) … this looks like a fish or something here swimming … this (pelvic area) could be a dead bird lying down or a lake … (long pause) … it’s something shaped like a person’s body … two legs and that looks like a guy’s moustache above the mouth (black area).’ 

The interviewer then said, ‘You said before that it looked like a little black seal’. The patient then continued: 

‘Like that’s something else in my head that I never thought of before … it looks like a man’s moustache … this is an apple on the tree and it looks as though he is reaching for it.’ 

Finally, the therapist asked him, ‘Is it a man or woman?’ He then responded as follows: 

‘Well, it’s a woman I’d say … looks as though she’s got lipstick on or something and that’s why I think it is a woman.’ 

In the opening phrases of his response the patient clearly substituted non-anatomical symbolic content for the structure depicting the body. Particularly noteworthy regarding his past feelings of sexual inadequacy is the response ‘dead bird lying down’. Next, attention might be directed to the fact that when the human figure finally succeeded in registering in consciousness, it was assigned a masculine connotation. This is remarkable since the picture is suggestive of the female rather than the male body. 

This avoidance of the feminine imagery is consistent with his past behaviour in relation to women. Finally, he was able to connect this distortion in perception. However, six months later, he saw it as the figure of a man. 

Heart Genitalia Card (VI)  

This picture presents anatomical content relative to the heart. More strongly embedded in the figure are cues relative to union of the male and female genitalia. 

The patient initially responded as follows: ‘This is an animal standing inside a red object which could be a cloud’. 

When under the drug, he stated: ‘That could be a giraffe with those things sticking out of its head … they could be horns (central object) … and it looks as though he sees something coming and is standing on the other side of a bush or something … he’s standing in a bush … this is a bush (red area) … and this red thing here I don’t know what it is … I think that it could be a mop of hair hanging down, but giraffes don’t have hair, so I don’t know what it could be’. 

Again, the patient substituted non-anatomical imagery when his consciousness was stimulated with material resembling the body. However, at the termination of the drug session when informed that the picture had anatomical content, he then stated that it looked like the ‘vagina’. In this situation the organ image of the more anxiety-laden female genitalia, rather than the cardiac aspects of the configuration succeeded in registering in consciousness. It suggested that, at this time in the study, he had been partially desensitized to mentally processing sexual imagery. 

In the retest situation, six months later, he initially failed to detect the anatomical content but when reminded of it reported once again seeing a ‘vagina’. When it was further suggested to him that some people see the central object as a ‘penis’, he became markedly anxious refusing to accept this possibility. In other words, when confronted with imagery depicting union of male and female genitalia, he totally blocked this from consciousness. 

Body Gestalt Card (II)  

This card evaluates an individual’s ability to organize separate components of the body into an overall image in the form of a gestalt (e.g., ‘a person with a big smile’). It consists of three separate units arranged in such a fashion to depict the human form. The top part was created to elicit projective responses related to the head. The middle part depicts the oral region but is sufficiently ambiguous in outline to present suggestive imagery relative to the heart. The lower black area represents the arm, body and legs. 

Initially, the patient responded only to the latter seeing it as ‘a person with his hands up in the air’. This failure to respond to the other aspects of the figure suggests that the patient had somatic anxiety in the regions depicted (e.g., ‘mouth’, ‘heart’). 

Under the drugged state, he responded as follows: 

‘There is a person … the top part is an animal … it’s got two heads and it only has one leg … this looks like a person in a drawing and this is his body, and this is his leg … and this is somebody’s mouth’. 

It is apparent that in the retest situation, he failed to resolve the separate components of the image into a gestalt. Moreover, his response to the upper black area as depicting an animal with two heads and only one leg is highly unusual. The missing leg in the response may be interpreted to reflect his own undue ‘castration anxiety’. Also, it is noteworthy that the drug relaxed his inhibitions to the extent that he could see the ‘mouth’, although, it was separate from the rest of the picture. It might be noticed that a pattern is forming, whereby the exhibitionist failed to recognize anatomical structure in the pictures. The other feature involves themes related to the oral region. 

For comparison purposes, an outline will be given of his responses to two anatomical pictures, which lack direct sexual referents. 

Chest Cavity Card (IX) 

This picture illustrates the ribcage and heart to a very high degree and is invariably so recognized by most subjects. Yet this patient saw ‘two people eating’, failing to recognize the anatomical content which is so strongly present in the picture. Under drug conditions, he stated that it looked like ‘the shape of a person’s head … that’s the girl’s hair hanging down … but then it could look like … oh, it reminds me of a couple of seahorses or something … and this is their tails … that’s their bodies and that’s their heads … and they are eating some kind of food or something … don’t know what it is … that’s the rippling of the water … oh, these are seahorses’. 

This illustrates how the patient inhibited not just phallic material but other somatic imagery as well. 

<Level B>Discussion 

A PT employing a series of newly designed anatomical pictures has been developed to stimulate somatic imagery. This approach has been illustrated in a patient with exhibitionism. A marked resistance was observed in fully registering sexual images in the consciousness. This finding may be appraised in the context of an existing theory partially derived from more traditional psychoanalytic procedures (Fenichel 1945). The extreme perceptual inhibition of the phallic imagery observed in the present study has certain theoretical implications. There is a definite parallel between this and the view that in exhibitionism, the individual unconsciously says: ‘Reassure me that I have a penis by reacting to the sight of it’. The subjective feeling that his penis might disappear becomes highly plausible to the outsider if one considers the excessive repression of sexual imagery noted in the exhibitionist studied. It is quite understandable how an observer’s response to the exposed penis could well provide a useful external source of reality testing for refuting this pathologic body fantasy. It might be noted that this perceptual defence has also been observed in tachistoscopically exposed illustrations of human anatomy to subjects with focal somatic anxiety secondary to psychophysiologic symptoms (Cassell 1966). 

Another theoretical formulation of exhibitionism is that the patient is choosing women as observers of the deviant behaviour and, in a magical sense, is unconsciously saying: ‘I show you what I wish you would show me’. This is considered to deny the apparent castration of the female’s body, reducing the fear that this might happen to him. It may be recalled that the patient’s responses to Cards II, III and VII (retest) were consistent with what is implied in the psychoanalytic construct ‘castration anxiety’. His phobia-like aversion to processing imagery related to the female body was observed in Cards VI and VII. 

Attention might also be directed to the patient’s tendency to project oral rather than genital themes in viewing the pictures. It’s consistent with the thesis that the exhibitionist is ‘an infantile individual’ concerning his sexually deviant behaviour (Karpman 1948b). Along the same lines, perhaps it is pertinent to recall that Kinsey found 20 per cent of pre-adolescent boys who engage in sexual play have exhibitionism as the limit of the activity (Kinsey, Pomeroy, and Martin 1948). It is suggested that this regressive aspect has functional significance in that it avoids the anxiety stimulated by sexual imagery. 

Another subject for discussion concerns the observation that—like the present patient—exhibitionists in general are sexually inhibited (Rickless 1950). In this context, brief attention might be given to the psychophysiologic aspects of normal sexual functioning. Sexual arousal in a ‘normal’ male involves the interaction between a physiologically originating drive and mental imagery relating both to his genitalia and to evocative images pertaining to that of a woman. For the exhibitionist under present study, sexual tensions would have to be intense before the resultant union of male and female imagery would register in consciousness and motivate normal heterosexual behaviour. It was suggested that abortive attempts to discharge these occurred when the patient acted out sexually in a state of excitation by impulsively exposing his genitalia. As was evident in the retest situation, exhibitionistic behaviour of a homosexual nature was also attempted by the patient to provide a release for his sexual impulses. 

Of course, as might be expected with the introduction of a new technique, all results do not fit the previous theoretical frame of reference. The above formulation may be seriously challenged since the patient was remarkably insensitive to detecting all anatomical content in the pictures—sexual or otherwise. Thus, there was evidence of perceptual inhibition of images depicting the lungs, mouth and heart. While it may be contended that the oral region and the heart provide imagery during states of sexual arousal (Schneider 1956, 1957), it might appear that the data do not strongly support a specific defect in the patient’s perception of the genitalia. However, since the patient did not show psychosomatic symptoms in other regions of the body schema, this thesis warrants consideration. Moreover, during therapy, he was found to be made more anxious by the discussion of sexual themes—rather than those relating to other aspects of the body. Therefore, probably, the primary disorder involved aversion to the genitalia, which secondarily spread to involve other somatic regions. 

The patient’s avoidance of female anatomy in the pictures recalls mechanisms operating in phobic disorders (Snaith 1968). While the two conditions differ in that the exhibitionist also avoided material presumably related to his own body rather than an external object, the comparison has heuristic value. Further, it has certain theoretical implications in terms of therapy. For example, it is tempting to consider that just as certain clinicians may treat phobic disorders through desensitization procedures, the same general principles might be applied in reducing anxiety related to conjuring up in consciousness scenes involving union of male and female genital imagery. Indeed, the way the therapist assisted the patient in mentally processing sexual images under narcotic relaxation employed insights borrowed from both behavioural and gestalt therapy procedures (Perls, Hefferline, and Goodman 1951). However, to be sure, it did not seem to have much ‘lasting’ effect since repression still occurred in the follow-up session six month later.