From the above account, one cannot escape what is most central to and best understood in psychoanalysis, namely, sexuality as a dynamic force in the etiology of various neurotic conditions. This has been one of the most important discoveries of psychoanalysis and is important to all psychoanalytic treatment. However, one should not let this obscure one’s view of what psychoanalysis is about and what it is for. I will take the rather strong position here that psychoanalysis is not a specific treatment for sexual disorders. There are other therapies that contend for that honor and perhaps come nearer to filling the bill than psychoanalysis does, although in my judgment we are far from having achieved anything like an effective, therapeutic approach to such difficulties. Even the best of such sex therapy techniques, employed by the most experienced and skilled clinicians, yield results that are less than satisfactory in a large number of cases. We now have only a poor understanding of why such specific therapies are relatively successful in some cases yet seem to fail over the long-run with many.
The implication of my statement that psychoanalysis is not a specific therapy for sexual disorders is that, in my judgment, psychoanalysis would not be indicated simply because a patient suffers from some sexual disorder. That a patient is frigid or impotent or suffers from premature ejaculation is not sufficient grounds for treating such a patient in psychoanalysis. When patients suffer from more deeply engrained and enduring forms of sexual disturbance relating to various forms of perversion, fetishism, transvestitism, homosexuality, psychoanalysis is still not a specific treatment, in my judgment, but in such cases there are almost inevitably other grounds upon which the decision to enter psychoanalysis might be made. In the latter sorts of cases, there are usually long-standing personality defects and impairments, or neurotic conflicts underlying the disordered sexual behavior which call for a deep and thorough analysis of the patient’s object-relations, both those in his current life and those in the past, as well as re-examination and regressive reworking of the patient’s developmental experience itself. Psychoanalysis is the specific therapy for such an undertaking.
Not only can it be said that psychoanalysis is not a specific sexual therapy, but in implementing its efforts psychoanalysis does not focus on the sexually disordered symptom. Sexual behavior together with its associated wishes, fantasies, attitudes, impulses, dreams, and so on, are subjected to careful examination in an effort to gain a deeper understanding of their meaning in the patient’s life and in connection with underlying conflicts and their developmental roots. As analysis progresses, as conflicts are reopened and re-examined and gradually resolved, and as the therapeutic changes begin to occur, particularly those modifying superego dynamics and increasing autonomy and conflict-free operation by the ego, the symptoms begin to wane. Not only do they become less frequent in the patient’s experience, but their compulsive and often driven quality seems to become less intense so that the patient gradually becomes relatively symptom-free.
The hysterical female patient who had suffered from frigidity finds her orgastic potential increasing and becoming more readily available, as she is able to work through the underlying oedipal conflicts and to recognize that her symptoms are related to underlying conflicts over sexual impulses towards her father and their gratification. As this aspect of her symptoms becomes more consciously apparent to her and is gradually resolved in the treatment, the symptom of frigidity is also resolved. Similarly, the young man whose difficulties with premature ejaculation have caused him considerable embarrassment and difficulty, finds that as he is able to handle more effectively his conflicts over aggression and self-assertion, and is able to surrender his somewhat infantile position of inadequacy, he too finds that little by little the annoying symptom seems to dissolve and disappear. In none of these cases was the analytic effort directed at the symptom itself, but rather to the underlying personality configurations, conflicts, and developmental issues pervasive influencing the patient’s life, of which the sexual symptom was merely one limited expression.
The issues in such symptomatic cases are somewhat different from the more deeply engrained perversions, particularly homosexuality. Recently analysts have directed a great deal of attention to homosexuality and the possibilities for its treatment. Certainly the attitudes toward homosexuality have changed over the last three-quarters of a century. Freud’s opinion at the time of the Three Essays was that little could be done for homosexual patients except suppression of symptoms by hypnotic suggestion. The attitude among clinical psychoanalysts toward the treatment of homosexuality has become considerably more optimistic, although at the same time the awareness of the complex personality structure underlying homosexual symptomatology and behavior has deepened.
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