A First Major Obstacle

We have been impressed by the emerging contradiction between our emphasis on the need to thoroughly explore love and sex, work and profession, social life, and creativity as important sources of satisfaction with life—as well as sources of inhibitions, conflicts, and pathology in the lives of our patients—and the reluctance that psychoanalysts and psychoanalytic psychotherapists frequently show when it comes to the exploration and management of these domains, especially sexual problems. From beginning therapists to seasoned psychoanalysts, we have found a remarkable reluctance to explore the details of patients’ sexual experiences, fantasies, and interactions and the erotic elements of transference and countertransference as they become apparent from the very first encounter with a patient. Part of this reluctance may be related to cultural conventionalities, but part also seems to relate to a puzzling decrease of interest in erotic life within psychoanalytic literature. Leading psychoanalytic theoreticians, such as André Green (2010), have expressed astonishment over the neglect of infantile sexuality. Ruth Stein (2008) wondered to what extent eroticism was being neglected in the middle of contemporary controversies between drive theory and object relations theory. The centrality of infantile sexuality seems to have become an orphan in the midst of this debate. The fact that strong cultural taboos remain regarding infantile sexuality seems obvious. Empirical research on the observation of the erotic behavior of infants and children has practically disappeared, with scant research dollars available for this line of inquiry.

In our work, it is evident that erotic elements play an important role in the initial evaluation of patients. Therapists do get an immediate sense of the degree of erotic attractiveness, inhibition, or repulsion evoked by patients—the extent to which aggressive erotic display and seductiveness, rigid inhibition, and significant dissociation between love and tenderness, on the one hand, and erotic desire and excitement, on the other, is an important aspect of the patient’s difficulties. By the same token, therapists’ correspondent countertransference reactions may indicate an important conflictual area to explore in the treatment. Patients may be erotically attractive or repulsive, and frequently seem to be so totally asexual that the thought about this subject does not occur to the therapist.

In theory, therapists—and especially analysts—are aware of the importance of systematically exploring patients’ sexual fantasies and activities, preferences and inhibitions, and the role that erotic feelings and behavior have as part of their relationships, both in intimate relationships of sexual love and in their demeanor within the social context. A certain degree of erotic tension is always part of what emotionally characterizes group behavior in social networks. Very often, despite an initial history that reveals significant sexual difficulties, a dissociation of sexual material from other areas of the patient’s experience may develop, contributing to making his or her actual erotic behavior “disappear” from the discourse.

For example, one patient consulted a senior psychoanalyst for a significant inhibition in her sexual response. She was able to achieve mild excitement after sexual penetration, followed by a gradual disappearance of her erotic response during intercourse, and then total incapacity to reach orgasm in any kind of sexual interaction with her partner. Interestingly enough, this symptom disappeared from the subject matter of the analytic sessions and had not been taken up at all during the next 3 years of standard psychoanalytic treatment, in which very important oedipal conflicts and competitiveness had been explored in depth. Patient and therapist may establish “bastions” of silence (Baranger and Baranger 1969)—unconscious collusion to avoid sexual matters. Often, sexual behavior may be referred to in such general terms that any real information is lost. “We had a very good sexual experience last night. It was great, very different from other times.” That seems like the beginning of an explorative dialogue, but, in fact, no further exploration occurs.

This practical problem is matched by subtle shifts in the focus on dominant psychological conflicts within a psychodynamic approach. In recent times, new knowledge regarding early attachment, and of the psychopathological consequences of insecure attachment and its central role in the development of object relations, has, appropriately, been at the center of attention of psychoanalytic thinking regarding early development. However, these advances have been accompanied by a significant neglect of the erotic element of early development. Contemporary knowledge of the neurobiology of affects centers around the development of major affect systems with specific central nervous system structures, neurotransmitters, and hormonal components. These specific primary affect systems include the attachment system itself, the erotic affect system, and the play-bonding system—all of which imply positive, pleasurable, affiliative motivation—and the fight-flight and the separation-panic system as negative, aversive motivational systems. These primary affect systems may be viewed in the context of a general affective “seeking” system that motivates a general, positive exploration of the environment and provides reinforcement to the activation of other systems stimulated by environmental interaction. It is as if the concern with the development of secure or insecure attachment has displaced the attention to the other positive affect systems, particularly the erotic aspects of the infant–mother relationship. Clinically, the focus on the immediate positive and negative affective relations of couples, and of the transference itself, tends to be formulated in terms of an enmeshed, avoidant, or secure attachment, and the erotic domain remains in the shadows.

Primary dependence linked to the attachment system appears as the only major positive motivational source of the mother–infant relationship and reflects a frequent reluctance to consider eroticism and aggression as intimately involved in motivational systems operating jointly with attachment in the earliest internalization of object relations. The contribution of mother’s erotic response to her baby in evoking the infant’s capacity for erotic response at a primary unconscious level, as well as the unconscious induction of that capability in her interactions with the baby, is theoretically accepted, such as in Laplanche’s (1970/1976, 1987/1989, 1999) work, but this contribution tends to be neglected clinically. Ruth Stein (2008) refers to the importance of this primary erotic induction and its role in originating a mysterious, exciting, oceanic experience that will mark a sharp differentiation from the experience of ordinary normal living, determining a lifelong tension between reality-oriented, rational self experience and the passionate expansion of the sense of self as a limitless subjectivity.

Independently from psychoanalytic explorations, Bataille (1957) concluded in his study of eroticism that human experience was marked by a sharp isolation between experiences controlled by the sense of time and space and objectivity, and other existential ones, with a sense of infiniteness, subjectivity, and transgression of ordinary limits and boundaries in contrast to the adaptive boundaries in the stabilized experience of reality. Sexual and religious ecstasies represent such experiential conditions. One may translate these two realms of emotional experience as a function of adaptation to social reality, on the one hand, and the tolerance of emotional freedom for a full and limitless exploration of subjectivity, on the other. They represent a duality that provides interest and liveliness to daily experience. The elimination of the passionate world would reduce life to a dull, constricted realistic functionalism, whereas an exclusive immersion in the subjective world of passion would become self-destructive and cause the loss of boundaries in relation to reality, including extreme self-destructiveness as the result of the search for total, unlimited pleasure.

A Mature Capacity for Successful Love

What can we expect as the ideal of a mature capacity for sexual love, as expressed by an integration of eroticism and tenderness, idealization and responsibility, enjoyment and passion? By ideal, we do not imply unrealistic goals with the implication that patients should live up to them, but a frame of what might be optimally possible in order to highlight the greatest difficulties to achieve such a condition. What are the most severe limitations determining the distance that separates the patient from the rich life that he or she might have? We are not talking about an ideal of “normality,” but a theoretical outline that facilitates the diagnosis of problematic issues that restrict the capacity to love. To begin with, such an outline should include a sharp focus on the capacity to experience sexual pleasure proper, to establish object relations in depth, and to establish one’s own and joined value systems in the relationship within a couple. An optimal way to evaluate the capacity for maturity in loving is to evaluate a patient who is involved in a love relationship or has been in a love relationship that can be explored as such.

General Preconditions for the Therapist

To penetrate a patient’s intimate sexual world is a complex and delicate aspect of the exploration of the patient’s pathology. The therapist’s personal freedom from unresolved sexual conflicts becomes an important aspect of his or her capacity to register the complexity of the patient’s sexual life. We assume that psychoanalytic training frees candidates from major blind spots and that the therapist’s own sexual difficulties should have been explored and resolved. In practice, however, at the Personality Disorders Institute at Cornell, we have found in careful supervisory work with experienced psychoanalysts, as well as with beginning or relatively young therapists, that countertransferences to patients’ sexual experiences constitute an important potential limitation to the therapist’s freedom for full exploration of this complex area, and that some general characteristics of the therapist’s personality may represent important compensating factors that permit the analyst to be open to patients’ problems beyond limitations in the therapist’s personal sexual life. We have found that it helps if the therapist has a full personal love life, including a fully satisfied sexual life with a degree of freedom of sexual fantasy, play, and exploration in the context of a gratifying, stable love relationship. These conditions help the therapist to be alert to the patient’s limitations in this area and to be able to explore them without undue inhibition or emotional distance. It also is helpful when the therapist feels comfortable with the awareness of his or her and others’ reaction to the erotic component of all social interactions, the awareness of sexual “vibes” emitted by or absent in others and himself or herself in social situations. Sometimes, a striking intensity of conscious or unconscious seductive “irradiation” and different degrees of erotic response by the therapist may be evoked by patients, with or without the therapist’s being disturbed by them, potentially broadening the therapist’s understanding of the patient’s sexual conflicts.

Ideally, the therapist should relate to the dialectic referred to in Bataille’s (1957) approach to psychic experience—that is, the freedom of shifting between times of reality-based, objective work focused consistently on dealing with daily life tasks, challenges, and interactions, and times when, under controlled circumstances, it is possible to “let go,” to submerge oneself in an intense, passionate sexual encounter, in the ecstatic reaction to a work of art, in an experience of friendship, in a state of religious ecstasy, or even in the unpredictable intoxication related to drugs. This statement could be misunderstood as proposing some built-in “psychoticism” in the therapist’s personality, which is certainly not the intention or the clarification of this point. It is a matter of being open to ecstatic experiences: sexual, artistic, religious.

In the description a patient gives about his or her sexual life in the initial encounter as part of the diagnostic evaluation of patients with severe personality disorders, we have found it helpful to be open and alert to the availability or the foreclosure of any erotic aspect of the emotional atmosphere that evolves between the therapist and the patient. It is helpful when the therapist has the capacity to transcend the conventional internal restrictions on such a freedom to explore the erotic dimension in the relation with the patient in the therapist’s fantasy, given the patient’s gender, age, and pathology.

Given his or her internal freedom, the therapist will be better able to explore fully the patient’s sexuality during the treatment. The barrier to homosexual identification that may evolve between a homosexual patient and a heterosexual psychotherapist determines one particular difficulty in the exploration of the patient’s sexual life. The therapist should acquire the freedom to identify fully with the vicissitudes of the sexual life and experience of all patients, including the case of homosexual therapists exploring the sexual life of heterosexual patients. In theory, we take this for granted, but practical experience frequently reveals potential limitations, inhibitions, and uncertainties in the therapist’s capacity to identify with patients’ erotic experiences. Obviously, the therapist’s capacity for empathy with different sexual experiences is relevant in the evaluation of patients with organized perversions.

With cases of serious sexual inhibitions and the restriction of organized perversions, primitive sexual countertransferences may emerge during the treatment that the therapist may have difficulty tolerating and must analyze regarding their relation to the patient’s projective processes. It is important that the therapist tolerate primitivity in his or her own sexual fantasy life. A consequence of the degree of sexual freedom the therapist possesses regarding his or her sexual life and fantasy is the capacity to confront the patient fearlessly with his or her difficulties and to explore the patient’s sexual fantasies and experiences in depth without a seductive attitude or a superego-derived critical one. This necessarily includes being able to confront the patient with painful aspects of sexualized transferences with concern for the patient and the trust that the patient will be able to capture this attitude of the therapist.

Diagnostic Evaluation

What follows are some further thoughts regarding the diagnostic evaluation. I have described elsewhere the structural interview as a method that is particularly helpful in the evaluation of patients with severe personality disorders (Kernberg 1984), and I shall limit my comments to focus on the evaluation of the patient’s sexual life within the context of that interview. It is important to obtain detailed information about the patient’s love life and his or her sexual experiences. The old-fashioned concern that detailed history taking would interfere with the development of the transference and the assumption that the important issues in the patient’s sexuality and love life would emerge naturally during the treatment, rather than artificially distorted in a focused exploration, has proved false in our clinical experience. Detailed initial evaluation permits arriving at a better diagnosis and treatment indication, and it provides an important source of information that will become relevant in orienting the therapist at later points in the treatment, even more so as the patient’s life situation changes in the context of the treatment, with new understanding, elaboration, and working through of the patient’s past.

We are interested in the extent to which there is a true capacity for commitment in the patient’s love relations, capacity for full enjoyment of the sexual aspects of the relationship, and the commonality of aspirations, goals, and value systems of the couple. If the patient is significantly involved with a partner, we explore the patient’s awareness of the personality of that person as part of the structural interview revealing the patient’s capacity for object relationships.

The exploration of the patient’s sexual life includes exploring the nature of his or her sexual behavior, the capacity for sexual interest or arousal, the freedom to approach a love object sexually, the increase of sexual excitement before and during intercourse, the capacity to reach orgasm, the frequency of sexual interactions and orgasm, the freedom to employ fantasy and play in his or her sexual activities, the freedom from undue shame and guilt over sexual intimacy, and the extent to which his or her internal freedom is reflected in the capacity to respond positively and openly to this inquiry. The frequency of the patient’s sexual activity (both interactional and masturbatory), the degree of satisfaction, and the nature of his or her sexual fantasies are important as well as the frequency and the nature of dreams with sexual content. Masturbatory fantasies, particularly frequently repeated specific scenarios, are an important window into dominant conflicts in the patient’s sexual life: the unconscious conflicts condensed in such stable scenarios gradually may be clarified during psychoanalytic treatment.

The therapist’s countertransference disposition will provide parallel information as an assessment, as well as a response to the patient: whether the patient is attractive or not; whether the patient seems to be emitting sexual “vibes” or not; whether the patient is reacting in a paranoid, inhibited, rejecting, seductive, or provocative way; and whether the patient is presenting himself or herself, by means of demeanor, clothes, or attitude, as a person who would make an attractive impression on others, or a seductive one, or a disgusting one, or a suspicious one. Age and gender of the patient may influence the direction and sequence of questions. An important countertransference element may be the therapist’s reluctance to fully explore the sexual behavior of patients with a great difference in age: adolescents being seen by older therapists, and older patients being seen by young and relatively inexperienced therapists, typically illustrate sources of therapist’s inhibitions.

On the basis of this inquiry, it should be possible to assess the patient’s degree of sexual freedom, including the extent to which his or her sexuality is inhibited by guilt or shame reactions, is used in a proper context, is used in teasing or seductive ways, or is characterized by a harmonious integration into the patient’s thinking, behaviors, and fantasies. At the same time, while we gain information about the quality of the patient’s object relations from descriptions of sexual partners, we are alert to indications of severe identity diffusion. The extent to which the patient’s capacity for love, emotional intimacy, and passionate commitment is integrated with sexual desire and freedom—or the extent to which there is a severe dissociation between the capacity to love on the one hand, and for sexual excitement and erotic interest on the other—can be diagnosed in this context. There are patients with full development of an intense and varied sexual activity who evince a traumatic or narcissistic limitation in their capacity for object relations, and impulsive sexual encounters replace the capacity to establish love relationships, whereas other patients reveal a capacity for object relations in depth in the context of significant inhibition of their sexual freedom. The extent to which polymorphous infantile sexual components are integrated into the adult patient’s sexual life, or the extent to which the patient is restricted to one particular infantile sexual trend (in the case of perversions), needs to be connected with the freedom or restriction of the object relations that the patient is able to establish.

An important element that emerges during this inquiry is the nature of the patient’s superego functioning and the extent to which there is excessively severe superego pressure expressed in exaggerated experiences of guilt and shame. Alternatively, in cases of severe impulsivity and chaos in the expression of sexual impulses, one issue may be the extent to which failure or deficiency in superego functioning is involved in the aggressive use of sexual excitement, seductiveness, and need to control, dominate, and exploit others. We are interested in the patient’s capacity for concern, responsibility, honesty, and consistency in his or her respect and treatment of sexual partners in contrast with sadistic dominance, irresponsibility, and exploitation. Patients who are involved in an intimate love relationship at the time of their evaluation facilitate the exploration of these major areas of the relationship of the couple.

Sexual Conflicts at the Level of Neurotic Personality Organization

In a highly simplified way, one might differentiate an overall level of unconscious conflicts at a neurotic level of personality organization from one at a borderline level of personality organization in terms of the predominance of advanced oedipal conflicts within the neurotic range of pathology versus the predominance of unconscious conflicts related to preoedipal aggression condensed with archaic oedipal conflicts in borderline personality organization. Predominance of advanced oedipal conflicts is reflected in unconscious guilt over oedipal sexual impulses and characterologically structured self-affirmative and self-defeating behaviors reflecting such unconscious guilt. The unconscious search for triangular relations as an expression of oedipal conflicts is frequently enacted, particularly with direct and reverse triangulations: a tendency to be fixated in self-defeating, frustrating love affairs, and an unconscious intolerance of potentially happy love relations. Being abandoned by one’s love object’s choosing a rival or one’s unhappy love for somebody committed to somebody else represents direct triangulation. Reverse triangulation may be reflected in infidelity, simultaneous love relations with two partners, or the revengeful abandoning of a love object. Frequently, oedipal guilt is reflected in various degrees of sexual inhibition, dissociation between idealized love relations accompanied by sexual inhibition on the one hand, and sexual freedom in relationships that are frustrating or devoid of emotional intimacy on the other. Masochistic sexual promiscuity, represented by a series of unhappy love relations, needs to be differentiated from narcissistic sexual promiscuity, which is an endless sequence of temporary idealizations and rapidly following devaluations that destroy all relationships within a limited period, or else stable but superficial object relations accompanied by dissociated sexual promiscuity.

A hallmark of the neurotic level of sexual conflicts is the capacity for establishing object relations in depth, the tolerance of ambivalence in love relations with deep and stable commitments, and the capacity for interest in and availability in depth to a love life with another person with whom a deep mutuality of understanding can be established. In contrast, in borderline personality organization, the predominance of splitting mechanisms and related primitive defensive operations, particularly projective identification, is reflected in chaotic relationships and the incapacity to appreciate in a realistic and deep way both the partner’s personality and his or her own. This basic situation is further complicated in the case of narcissistic pathology, in which lack of the capacity of investment in love relations is reflected in a typical, chronic dissociation of sexual interests from shallow emotional relations and, under extreme circumstances, a practically complete replacement of any sexual intimacy by almost mechanical sexual encounters, “Internet sexuality,” or a total sexual inhibition reflecting the loss of any sexual interest.

Intensive, long-term psychoanalytic psychotherapy or psychoanalysis represents a symbolic replica of the oedipal situation, an ongoing intimate relationship that fosters the patient’s development of sexual desire with a person—the therapist—with whom an intimate relationship develops, of particularly sexual openness on the part of the patient, while total implicit prohibition of any sexual involvement replicates the inhibition of the original oedipal scenario. The difference between the original oedipal situation and the treatment situation is the possibility of full exploration of oedipal desires: their frustrations and related conflicts, the development and exploration of disappointment reactions, resentment because of the unavoidable nonavailability of the oedipal object, and eventually the sublimatory resolution of the conflict within the openness to and search for alternative, realistic gratification of intimate sexual love and commitment in external reality.

A lack of resolution of oedipal conflicts at a level of neurotic personality organization is most typically expressed in the pathological reaction to experienced rejection or abandonment by a love object that reinforces the neurotic desire and passionate love toward unavailable objects. This may become a major resistance in the transferences of neurotic patients with masochistic personality structure, replicating in the treatment their temptation for the search for impossible, unavailable love relations in external life. Defensive, aggressive deterioration of love relations with clearly available but unconsciously guilt-provoking oedipal objects is replicated in transference developments of hostility and competitiveness as defenses against underlying erotic impulses. Typically, however, all these conflicts develop in the context of a capacity of a relationship in depth, and aggressive oedipal competitiveness, revengefulness, or defensive reactions against dependency and against intimate involvement are expressed in the context of such a potential for an object relation with depth and commitment.

In contrast, under conditions of borderline personality organization, the activation of aggressive impulses reflects a condensation of conflicts of oedipal and preoedipal nature, with predominance of preoedipal aggression, primitive aggressive impulses, and defenses against related, frustrated early dependent needs, and the predominance of sadomasochistic over loving experiences from earliest life on. Here, all dependency is charged with mistrust and resentment, and the need for omnipotent control and revenge, in replacement of the capacity to enjoy realistically available dependency. The need to deny all dependency upon a hated and envied parental object complicates these dynamics further in the case of narcissistic pathology.

The following case illustrates the nature of the conflict that facilitates the differential diagnosis between a relatively high-level, neurotic structure and the particular condensation of conflicts typical for borderline personality organization.

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