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Critique of Otto Kernberg’s Article:
A Severe Sexual Inhibition in the Course of the Psychoanalytic Treatment of a
Patient with a Narcissistic Personality Disorder
by
Gabrielle A. Kortsch
SYNOPSIS OF KERNBERG’S ARTICLE
After the failure of two marriages in which he demonstrated emotional and sexual
indifference, a 45-year-old businessman entered psychoanalysis. When single, he tended to
sexual promiscuity with women to whom he felt superior. After his second divorce he recognized
his inability to maintain any relationship that threatened his well-being. Initially treatment focused
on his narcissistic personality structure, uncovering forgotten childhood memories and reliving
parental relationships. As he improved, forming an emotionally stable relationship and marrying,
terminating psychoanalysis was contemplated. He immediately developed an extreme sexual
inhibition. A medical consultation however, proved he was in prime condition. In order to deal
with anxiety underlying intense fears over sexual engagement with his wife and of speaking of
these fears, analysis of pre-oedipal and oedipal conflicts in transference and counter
transference brought about the resolution of the problem.
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“There is a high-desire and a low-desire partner on almost every marital issue…” 1
“…in our culture the claims of the body are denied.” 2
“What is it that we demand of sex, beyond its possible pleasures, that makes us so persistent?” 3
While Klein refers to inhibited desire as the “recognition that sexual desire is not what it
might be, what it should be, what it used to be, or what it is with a different partner” (1997, p.
203), Schnarch states “that ’high desire’ and ‘low desire’ are systemic positions in every sexual
relationship, and that these positions are typically reflective of other (deeper) issues (Leiblum S.
& Rosen, R., 2000, p. 17). Kaplan even compares hyperactive sexual desire to obesity and
bulimia and hypoactive sexual desire to anorexia nervosa, since the former pair represent “a
pathological or dysfunctional lack of control over the respective function” (1995, p. 19), while the
latter pair “are analogous in that both conditions represent a loss of an appetite as a result of
pathologically excessive overcontrol” (1995, p. 19).
Kernberg’s article (see Synopisis, above), while appearing, at first glance, to deal with a
patient’s narcissistic personality disorder, is, in fact, a case study of the emergence of a deeprooted and underlying severe sexual inhibition “that developed as a new symptom in the
termination phase of psychoanalytic treatment” (1999, p. 899). Klein writes that desire issues
may come into a clinician’s office under the guise of something totally unrelated, or “in the
context of something else entirely“ (1998, p. 205). It is this nucleus, this core of a problem woven
underneath the tapestry of another, which gives this article such particular interest, since clearly,
it is a roadmap of sorts even for those practitioners who encounter a sexual desire disorder that
has already become apparent, since this methodology points the way towards a particular
1
Schnarch, 1998. p. 329.
Lowen, 1975, p. 310
3 Foucault, 1990. p.79.
2
Copyright © Dr Gabriella Kortsch 2005
etiology – pre-oedipal and oedipal conflicts embedded in a narcissistic personality disorder - that
otherwise might not be so apparent.
Furthermore, the fact that in this case study the inhibited sexual desire did not make its
appearance until the psychoanalytic process was nearly completed, is cogently reiterated by self
psychologist Arnold Goldberg who “has emphasized the import of sexualizations that occur
around vacations and empathic disruptions” (Charlton, 1998, p. 316).
Kernberg has been steadfast in his application of methods espoused by the Freudian
psychoanalytic school in determining the treatment for his patient. Whether or not this is the most
ideal, and most rapid form of treatment for this particular disorder, is not the issue, as much as
the fact that thanks to this form of treatment for the presenting problem – narcissistic personality
disorder – this new (or emergence of an underlying) problem came to the surface, and was able
to be treated successfully by full application of Freudian methodology.
The patient had heretofore been active sexually, both with his two earlier wives – until shortly after the actual weddings, boredom set in and he lost all interest in them; with his frequent
sexual partners whenever he was not married, albeit always on a very short term basis, and
always without forming any kind of bond other than the blatantly sexual one; and finally, with his
third wife, with whom he also – for the first time in his life at the age of nearly 50 – enjoyed a
deeply satisfying emotional life. Nevertheless, as treatment closure loomed threateningly near,
he suddenly – and at first glance - inexplicably – developed the severe sexual inhibition with
which this case study deals.
Simply put, he was no longer able to function sexually with his wife at all. A complete
medical examination, which he insisted that Kernberg should request of him, turned out to be
crucial to the resolution of the case, since - although its results were totally positive; the patient
had no medical condition of any sort – its symbolic oedipal quality offered a great deal of
information. Oedipal, because apparently as a child, the patient had been dragged to doctors by
his mother in order to determine whether his genitals were underdeveloped, or his penis
deformed or twisted towards one side, or whether the size of his testicles was normal and that
they were definitely descended. This had eventually – along with rather late onset of puberty –
translated to a great sense of shame concerning the size of his genitals, in particular since his
mother called him a “shrimp”, and he felt he was a “shrimp” boy with a “shrimp” penis who now,
as an adult, in a stable and emotionally sharing relationship for the first time in his life, felt he
would never be able to penetrate his wife with said “shrimp” penis.
Kernberg states that the patient had transferred the feelings he had carried towards his
mother as a child to the clinician, and now considered that his sexual inhibition was Kernberg’s
problem, in particular, and most especially, because Kernberg had been “led” by the patient to
ask the patient to get the medical evaluation in order to replay and relive the childhood scenario,
relieving him of all responsibility in the cure of his sudden affliction.
With regards to the psychoanalytic approach to sexual disorders, Heiman writes that
“traditionally sexual dysfunction has been viewed as a symptom that expresses a pathological
process in personality development; a developmental arrest is thought to result from castration
fantasies, guilt over wishes for gratification with father, and unconscious fears. […] From the
perspective of object-relations theory, an individual’s capacity to relate to another is innate,
begins at birth, and is partly determined by an ability to form an internal representation of the
other. Later both negative and positive attributes of the caretaker are internalized, and these
engender the capability for relatedness in later life. Tolerance of the ambivalence brought about
by recognizing a loved one’s faults contributes to a person’s ability to maintain interest and
intimacy with another” (Heiman, 2000, p. 128).
It is precisely this which Kernberg begins to analyze so thoroughly with his patient once
Copyright © Dr Gabriella Kortsch 2005
the sexual inhibition had emerged, since it is clear that if despite professing to love and care for
his wife, and despite no medical reason to the contrary, the patient was unable to perform
sexually, that one of the underlying reasons – perhaps the main one – in determining this
dysfunction must lie in his relationship with his parents.
During this time the patient professed a “deep-seated indifference towards resolving the
sexual inhibition with his wife except by magical, ‘as-if’ means that would bypass the emotional
relationship with her, such as his identification with a ‘007’ personage” (Kernberg, 1999, p. 904).
The therapist’s analysis of this defense on the part of the patient against a “deep-seated
insecurity about his sexual power, a fear of failure and impotence” (Kernberg, 1999, p. 904) led to
a growing sense of anxiety about his sexual performance and the size of his genitalia, along with
a renewed transference, but in this instance to a warm but weak father image.
At this point in the analysis the patient was once again becoming aroused by his wife,
although at such times he would develop intense anxiety and be fearful of “being unable to
maintain an erection, and of her making fun of him or depreciating him” (Kernberg, 1999, p. 904).
Over a period of time this anxiety grew so strong, and coupled with further transference, this time
to a dangerous, threatening childhood image with whom the patient felt he could not compete
sexually, that on occasion, while in the therapist’s office, the patient would actually fall asleep
“precisely following moments at which intense anxiety had been stirred up in him” (Kernberg,
1999, p. 905). Clearly, Kernberg analyzed for him, these moments of precipitous sleep were an
effort to avoid exploring the issue of the relationship with his wife.
Ultimately, Kernberg’s probing, his harvesting of the patient’s childhood memories, as well
as his analysis of the process of transference and countertransference which “led to the symbolic
repetition of a childhood experience” (Kernberg, 1999, p. 907), brought about a resolution for this
patient, where not only the sexual relationship was restored to its former healthily active levels,
but the emotional relationship with his wife deepened as well.
While I consider Kernberg’s approach to this patient’s predicament both fascinating and
useful under limited circumstances, I do feel however, that other approaches might have brought
about a resolution in a more speedy and expeditious fashion, while opening some inner portals of
understanding in this patient’s mind, regarding his role in relationships, his withdrawal from true
emotional openness, and the richness inherent in self development through a loving relationship,
in particular, through an emotionally and sexually intimate relationship.
Freudian depth therapy is clearly something that can only be constructive for that finite
number of members of the human population who have a wealth of leisure and funds at their
disposal in order to partake themselves of it. Furthermore, it is much more suitable for those who
are indeed willing to plumb the depths of their psyche in this intriguing, albeit tedious fashion.
One cannot help but wonder as well, whether a jeremiad must be at the heart of one’s every
thought to even want to participate in such a long-drawn-out process, in order to be able to
reiterate time and time again the extent of one’s suffering, for in the 21 st century of instant
gratification on most levels, it seems dubious at best, to accept that someone would willingly
spend five to ten years in therapy, without having some kind of ulterior motive with tentacled
roots deeply embedded in the chthonic depths of the psyche.
Nonetheless, this process, as mentioned earlier, does have its finer points, in particular,
the manner in which it is able to point out the path towards the possibility of a connection to
narcissistic personality disorder being at the heart of some types of sexual inhibition, as well as
the fine manner in which the pre-oedipal and oedipal conflicts are woven into the analysis.
There are however, other schools of thought that may bring about a resolution much more
swiftly than that developed in this article. Sensate focus technique, for example, in order to allay
the patient’s fears and concerns regarding the size of his penis, and in order to draw attention
away from the orgasmic end product of lovemaking, and focus more on the quality of love in the
Copyright © Dr Gabriella Kortsch 2005
relationship, that after all, was so new to this particular patient, might have been of inestimable
value (Charlton, R.S. & Brigel, F. W., 1997, p. 252-256) in drawing him closer to his wife, as well
as in helping him overcome his feelings of inadequacy. Along with an intelligently run couples
therapy approach, the patient and his wife might have been very well served indeed.
Schnarch’s Sexual Crucible model (McReynolds, C. & Schnarch, D. ,1997, p. 127-164) is
however, in my opinion, the most viable model of all, surpassing by far Freudian pre-oedipal and
oedipal thought, in particular because of its twin concepts of emotional fusion4 and
differentiation5. “Most people don’t realize that relationship success also creates systemic
pressures that make balancing closeness and intimacy difficult. The more valued the relationship,
the more there is to lose. We feel more anxiety in being intimate in the sense of being honestly
and fully ourselves. Yet if we want passion, we need the spark and invigoration of intimacy. One
of the central dilemmas of sexual partnerships is that the more important a relationship becomes,
the more difficult it is to sustain passion. This is so because the tension between closeness and
intimacy becomes increasingly profound. The paradox of closeness and intimacy is that the only
way to really have either is to be willing at times to sacrifice closeness for the sake of intimacy. In
other words, to be liked we have to be willing to risk not being liked, for the sake of being known
accurately” (McReynolds & Schnarch, 1997, p. 141) (italics mine).
This – these words – show how we, modern-day alchemists, to use Jungian terms, may
be instrumental in converting nigredo to gold in the psyche of man in the temenos of our
practices, together with the belief, as Kottler puts it, that “the client has faith in us, as people of
integrity and wisdom, as experts with the power to heal” (Kottler, 1993, p. 7).
For further information about Dr Gabriella Kortsch and her work go to
www.advancedpersonalytherapy.com
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4
Copyright © Dr Gabriella Kortsch 2005
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Copyright © Dr Gabriella Kortsch 2005