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Introduction to Psychosexual Medicine: Session 4

COURSE OBJECTIVES

• To be familiar with different approaches to the treatment of sexual dysfunction

• To understand the use of the ‘doctor-patient relationship’ in psychosexual medicine

• To have confidence to manage presentations of sexual dysfunction in your normal practice

SESSION 4• Revision of session 3

• Basic psychoanalytic principles:1. Transference and Countertransference2. Defence mechanisms

• Case discussion

SESSION 3: REVISION

• List the approaches to psychosexual problems used in CBT

• Describe and explain “Sensate Focus”

• Describe treatments for male sexual dysfunction

Session 4: By the end of this session you will be able to:

• Explain what is meant by ‘transference and countertransference’

• List common defences and their application to psychosexual problems

IPM prospectus

1. Psychosexual Medicine is a type of brief therapy, based on psychoanalytical principles, but drawing on medical knowledge and skills, where appropriate.”

2. “Psychosexual Medicine is practised by doctors who understand how emotional factors, not always experienced at a conscious level, interfere with sexual performance and enjoyment”

Psychoanalytic (psychodynamic) principles

• The unconscious

• Defence mechanisms

• The influence of early relationships

• Therapeutic relationship, transference and countertransference

“Transference”

• “The experience of feelings, drives, attitudes fantasies and defences towards a person in the present..which are a repetition of reactions to ..significant persons of early childhood unconsciously displaced onto figures in the present”

• “It is a repetition and it is inappropriate”

Greenson 1967

Countertransference

• “The analyst’s transference on his patient”• Therapist derived: “the therapist contaminates the field with his

own feelings from elsewhere”• Patient derived: “What the doctor feels is part of the patient’s

illness”

Therapeutic use of countertransference

• The analyst must use his emotional response as a key to the patient’s unconscious”

• “By putting himself empathically in the other’s shoes, the therapist allows himself to feel what the patient has been unable to acknowledge in himself, such as anxiety or grief”

Defence mechanisms

• Strategies used by the ego to protect itself against anxiety.

• Usually developed in childhood and become unconscious and unhelpful in adulthood

Defences 1

• Repression - unacceptable impulses etc., are rendered unconscious.

• Rationalisation - self-deceiving, apparently rational "explanations" for instinctual behaviour.

• Intellectualisation - excessive use of intellectual processes to avoid emotional expression and experience.

• Denial -an outright refusal to admit or recognize that something has occurred or is currently occurring

Defences 2

• Avoidance- refusing to deal with or encounter unpleasant objects or situations.

• Projection -taking our own unacceptable qualities or feelings and ascribing them to other people.

• Regression -reversion to patterns of behaviour used earlier in development.

• Somatisation

Somatisation (conversion)

An emotional response to a stress is converted into a physical symptom which symbolises the conflict

A tendency to experience and communicate psychological distress in the form of somatic symptoms and seek medical help for them

The normal, unconscious process by which psychological distress is expressed as physical symptoms.

Applying psychoanalytic principles to psychosexual medicine 1

• Gives substance to your free floating attention• Awareness of transference allows doctor to respond in a more

helpful way• Countertransference can be used as a clue to the patients

unacknowledged emotions

Applying psychoanalytic principles to psychosexual medicine 2

Observation of defences can point to areas of difficulty

Understanding of defences helps avoid the temptation to ‘batter them down’

Pay tribute to the defences: ‘This seems very difficult to talk about’. ‘that’s a very painful story but I notice you are still smiling’

Quiz 1

• Catherine is asking for a chlamydia test. She has found out her boyfriend was cheating. She has tears in her eyes but insists it is all fine and she is completely over him.

• What defence/defences are displayed here?

Quiz 2

Claire comes for a smear. You happen to know she was married last year. You ask her when she last had sex and she tells you it was ‘about 5 months ago’. She tells you quickly about how she has been very busy, her husband has been away a lot, it will all be fine when they move in to their new house.

What defence/defences are displayed here?

Quiz 3

• John is asking for viagra. He is 30 and in good health. You ask him whether anything has happened to cause him to lose his erections. He tells you without any emotion about his mothers death of cervical cancer, how he lost his job, his girlfriend cheated on him.

• You suggest this might be a cause of his ED and he looks blank and shrugs.

• What defence/defences are displayed here?

Quiz 4

• Jane tells you sex is painful. She has no idea why, everything is fine, she was never abused, her husband is very understanding

• When you examine her she whimpers and speaks in a baby voice. She has marked vaginismus

• What defence/defences are displayed here?

Session 4: By the end of this session you will be able to:

• Explain what is meant by ‘transference and countertransference’

• List common defences and their application to psychosexual problems