The language of id analysis always carries the meaning that there is no good reason to be that way—that it's immature, weak, crazy, or bad. In other words, you just shouldn't be that way. 

Here I try to show how if the wife's behavior really is considered to be part of a system, then it hardly makes sense to say that this couple's relationship represents what the wife wants. That style of thinking is what leads us right back to traditional individual psychotherapy. And, more than that, it leads us back to classical psychoanalysis, in which people's behavior was always seen as reflecting what they really wanted. That was the big secret that therapists imparted to their patients.

In contrast, from the ego analytic point of view things are not quite so simple and straightforward. My aim is to show that ego analysis offers a way to identify with the wife, making it necessary to move her only slightly off the spot she is on to reach a reasonable therapeutic objective (which is why ego analysis is often brief).

I think I make a fairly good case here for the way therapists can too easily skip over the first few links in the causal chain, with the result being a long-term therapy rather than a definitive solution to a crisis. This actually was Kaplan's point of view too. It is the whole point of her immediate-versus-remote conception.The issue is what those first few links are supposed to be.

This paper was actually not written in response to Kaplan as much as to a paper presented by another well-known psychoanalyst and sex therapist, John O'Connor. He delivered his paper at the annual meeting of the Society for the Scientific Study of Sex in New York City. I was to deliver my talk ("The Myth of the Surrogate") after the lunch break. I saw him, like Kaplan, as representing a classical psychoanalytic model, in which everyone is a deviant and behavior has no valid present meaning. People are not seen as trying to do anything. Their behavior is not understood, only evaluated as falling short of norms that define maturity as little more than rationality and cooperativeness. I got energized and felt that O"Connor had to be answered then and there. So I wrote the first version of this paper during the lunch break and delivered it as the introduction to "The Myth of the Surrogate." This essay has had several lives. A refined version was published in The Journal of Sex & Marital Therapy in 1977, and I now have the chance, by posting it on the Web, to elaborate some of the points a little further.

This case report appears in Kaplan's chapter on "Results," and is given as an example of a couple with "deep-seated problems" that "cannot be bypassed," meaning that there was no way to help them to be sexually "functional" without getting into their issues, and they were not motivated for the long-term therapy this would require, nor for any kind of insight therapy. For this reason the case is a good vehicle to use as an illustration of an approach to uncovering that is not as dependent as is depth analysis on the patient's motivation for uncovering or for insight.

This is the case report, quoted in its entirety (pp. 444f.):
 

	Our files also include some cases of secondary impotence where the patient failed to respond to treatment. One patient in this group did not attain potency, not because he was unable to respond to the brief treatment procedures, but because of his wife's massive and relentless hostility. Whenever he appeared to be making progress, her feelings of anger were mobilized and she would immediately proceed to sabotage treatment. Thus, when he began to respond with erections on nondemand stimulation, to his extreme embarrassment she told their neighbors that her husband had been impotent but was beginning to improve. When he was finally able to have intercourse for the first time in eight years, she complained because (not surprisingly) she did not reach coital orgasm on that occasion. She insisted that only coital orgasm could satisfy her. She also refused to have intercourse in the morning, which the therapist suggested in order to take advantage of her husband's morning erections, on the grounds that he hadn't brushed his teeth yet. This wife's hostility and anger had their roots in the deep neurotic conflicts which surrounded her attitudes towards men. Apparently, her husband's progress in treatment served to reactivate these conflicts to the degree that she could not tolerate signs of his increasing sexual adequacy without experiencing rage. Moreover, in this instance, the wife's pathological reactions were too intense and urgent to be circumvented; treatment could not proceed in the face of such strong resistance. In cases where the destructive sexual interaction is due directly to massive psychopathology and/or marital discord which cannot be bypassed, the opportunities afforded by the new brief approach to resolve these deep-seated problems may be insufficient to enable successful treatment of the couple's sexual difficulty.

                                                     THE REPRESSION MODEL            
Most therapists would find nothing to take exception to in Kaplan's report. We read the examples given of this woman's "massive and relentless hostility" without question, despite its registering on us that these are not examples of open hostility. We even know from these examples that this is a woman who probably would not agree that she was angry at her husband at all, and who we expect would defensively deny both opposition to the treatment and resentment of the therapist.

All of us are so accustomed to the repression model that Kaplan need not mention that this woman's hostility was unconscious. As a result, we can easily overlook the significance of repression itself, loosely equating repressed and nonrepressed impulses, finding this woman to be as massively and relentlessly hostile as if she had literally attacked her husband, openly ridiculing him to the neighbors, had refused to have intercourse with him at all, teeth brushed or unbrushed, and had insisted that the therapist's suggestion to use morning erections was a rip-off.

All of us are so accustomed to a shorthand that skips over defenses and over the ego that it is still easy to neglect this side of the patient, despite the efforts of the ego psychologists to correct this bias. We are familiar enough with the obvious neglect of the ego by early analysts. To them, the conscious contents could be brushed aside, just as the defensive rejection of an interpretation proved its correctness. At the same time the success of early analytic therapy was dependent on the patient's readiness to eventually accept interpretations of repressed impulses, dependent, that is, on the strength of the "reasonable ego". The early analyst spoke of showing the impulse to the reasonable ego.

The patient had to be mature enough to tolerate having an alien impulse exposed without becoming unduly defensive or suffering an undue loss of ego integration. This requirement still holds even for sophisticated contemporary therapists as long as their goal is to penetrate defenses. Thus, in a footnote to the case I have quoted, Kaplan draws an instructive contrast with a similar case, one reported elsewhere in Kaplan's book, in which the wife's impulse to castrate her husband was successfully dealt with by interrupting sex therapy and treating her for an unspecified period in individual psychotherapy. Kaplan explains that what made this woman treatable in contrast to the present case was her basic stability and her recognition of "the irrational quality of her reactions."

Successful depth (id) analysis depends on the patient's commitment to rationality. Sager and Kaplan's approach to couple therapy is based on unearthing the irrational marriage contract (see Sager's chapter in The New Sex Therapy and also, Sager, Kaplan, et al., 1971).. The couple's unrealistic expectations are made conscious, and they are shown how self-defeating these expectations are and how they create a mutually depriving relationship. The success or failure of the cases reported depends on the couple's readiness to give up these expectations.

For therapists working within this perspective, the renunciation they look for patients to make does not appear to constitute a sacrifice. All that is to be given up is a stubbornly self-defeating and depriving position. In this perspective repressed expectations and the impulses they generate are thought to be repressed because they are so irrationally and stubbornly self-defeating. This is the perspective of depth analysis. Repression can be taken for granted since the pathological impulse is seen as intrinsically unacceptable to the ego.

In fact, patients who will not renounce unrealistic expectations and hostile impulses are considered by some depth therapists to be suffering from a narcissistic ego defect that makes them essentially untreatable. Although sex therapists typically have no such ideology, in practice they do not feel that their therapy can cope with deliberate, conscious defiance or rejection (of the partner or of the therapy). Which is to say that patients who believe they have nothing to gain by being reasonable or cooperative are typically screened out of sex therapy.

                            SPECULATIONS ON THE SIDE OF THE DEFENSE
Although Kaplan reports this case as one in which "bypassing" failed, from another perspective it is possible to see the wife as having already bypassed her rage and frustration, perhaps as much as it is possible. If from one point of view her refusal to have intercourse in the morning on the ground that her husband had not yet brushed his teeth can be seen as massive and relentless hostility, from another point of view it can be seen as a ludicrously feeble effort to represent her own interests. 

It is the inadequacy of the wife's complaint that can make her position seem so trivial, even comic. (When this paper was presented, and this reason for her refusal was given, the audience laughed.) We can see at once how unlikely she would be to pull for sympathy from her husband or from the therapist and, further, how unsympathetic, at some level, she must have been to her own position. Such antic defiance has to strike us as pointless, and is likely to alienate even the most tolerant of therapists. To be unwilling to subordinate herself to her husband's needs can easily seem merely to be spite.

Consider her complaint that she did not reach orgasm during her husband's first successful attempt at intercourse and that only a coital orgasm could satisfy her. Possibly the complaint that she needed to make was that she was not getting anything at all out of it, that she was feeling, at best, emotionally uninvolved. To complain instead that she had not reached orgasm might have been a desperate attempt at justification, since she might have believed that she had less of a right to complain about lack of feeling than about lack of orgasm, especially in sex therapy. As in the tooth-brushing example, she might have believed that reasons make better justifications than feelings.

This incapacity to make a convincing case for herself can be seen as a consequence of the repression of her anger. The resulting compliance may have been so total that she had no way left to say that she was not turned on or that she felt left out. All that remained was her querulousness. 

This line of interpretation leads to the conclusion not that she was angry at her husband, or at all men, but that she was unable to be, except in this limited and ineffectual way.

It is now a widely quoted and will-established belief that any couple can derive some benefit from the restoration of sexual functioning. Even if this change does not set off a benign cycle, some opportunity will have been created for relief from the stresses of their relationship. However this is only a half-truth. The other half of the truth is that sexual functioning may be dysfunctional. 

The case under discussion is a good one to use to make this point since the wife's behavior can seem so dysfunctional. Unprotected against the countertransference, the untrained therapist would have trouble inhibiting the reflex to scold this woman for being so contrary, to accuse her, no matter how subtly, of being castrating. The husband's apparent inhibition of any such reaction would make this an especially compelling response. The impulse to retaliate on his behalf could be irresistible. As it is, the therapist's sympathies were apparently on his side.

If it is easy in this case to see this woman's hostility toward her husband as pathological, it is easier to see hostility toward all men as pathological. Aside from any consideration of this particular case, it is one of our unfortunate prejudices that being angry at all men or all women, or everyone, is thought of as unrealistic and, hence, as pathological. It is especially unfortunate that one frequent effect of this prejudice is to exonerate the specific partner toward whom the patient's anger is directed. It is all too easy to see such anger as generated by past experience, which, of course, it also is.

Of course, there are therapists geared to help this woman get her anger out. The radical therapist might insist that she openly attack her husband ("Tell him, 'Sex with you is a rip-off!'"). The feebleness of this woman's complaints suggests that such a confrontation would only immobilize her further. My guess is that she would be reduced to defensively insisting that she is not angry, she just cannot stand bad breath, and she just wants coital orgasms. I think there is no way to do this without making such a patient feel accused.

By contrast, our approach might be to consider the retaliatory feelings provoked in us to be part of this couple's pathology, created both by the wife's inability to complain directly and the husband's apparently dogged and long-suffering efforts to respond sexually as if his wife were a receptive and aroused partner.

We might also guess that in expressing ungenerous reasons for withholding help from her husband, the wife must have expected to be scolded by the therapist, and so she would have taken her stand with some apprehensiveness, no matter how brazenly or blandly she had overcome it. We might then try to support her stand by pointing out how hard it is for most people to allow themselves to be finicky about odors because we all feel under pressure to be good sports in sex. We could add that she might even be able to detect in herself the impulse to swallow her revulsion and cooperate, both out of a sense of duty and in order to avoid being scolded.

When it came up, we might then similarly congratulate her on being able to refuse the suggestion "to take advantage of her husband's morning erections," pointing out that most people feel obliged to submit to therapists' suggestions. We would also try to further reinforce this refusal by recommending against her going ahead with sexual activity unless she feels aroused.

Perhaps our next move in this idealized sequence would be to tell the wife that we thought she did a poor job of complaining, that we thought her complaints were inadequately developed. We might then give her the homework assignment to work at complaining about her husband, either in face-to-face exercise or in writing. For her to make any attempt at all could take considerable prompting, including instructions to exaggerate and be unfair.

We would expect that after forgetting to do the assignment, then not finding time for it, then getting the instructions wrong, she would finally attempt it but would go blank or find herself immobilized. This could reveal that her problem is not her anger but her fear of her anger. For example, we might be able to show how her husband's vulnerability and his own inability to blame her for his difficulties force her to stifle her anger.

Approaching the case from this direction could bring us to a different conclusion than Kaplan's about this wife's attitude toward her husband's "potency" problem. She could be seen as needing him to be potent, not impotent, as needing him to stand her anger rather than to be destroyed by it. Our view might well be that it is his inadequacy that forces her to repress her complaints and to not be free to think about whether she is aroused. Conceivably, what she is most angry about is her husband's vulnerability.

Needless to say, this would all require delicate and attentive therapeutic handling since, at least as I have spun out my prototype of this couple, at any moment the wife is liable to succumb to feeling like a bitch and the husband is liable to move into depression and hopelessness. The goal would be not only to relieve the repressive (superego) pressure on the wife, but also to relieve the husband of feeling responsible for his impotence. Once he could see how coerced--and, therefore, turned off--his wife felt, he might then grasp the way that his symptom was not the responsibility of either of them but the expression of a problem in the relationship.

They would then be in a position to see how both of them were trying to go along with what a sexual relationship seems to require, in effect, imitating a sexual relationship without either of them feeling aroused. Much as my emphasis has been on the wife's inability to complain, she may have been closer to it than her husband since she, at least, was being the temperamental one, and so she may have been the best candidate to be trained as a spokesman for the mutual bind.

The goal would be to help her see, first for herself and later for both of them, how she has to submit in their sexual relationship, perhaps largely out of anxiety about disturbing her husband's sexual performance. We would try to help her to get in touch with how she feels totally turned off and hates going to bed with her husband, and in a way that would be relieving for both of them—her, because it explains her grudgingness about cooperating, and him, because it explains his erection problem as an inevitable expression of their mutually turned-off state.

Since this response contradicts what appears to be the obvious reality of her behavior, it can look like pure defensiveness. However, to take her response simply as denial can make this woman even more intractable. Unless the therapist can recognize the validity of her experience of putting up with a lot and getting nothing for herself, the therapy may well meet desperate, last-ditch resistance.

No matter how it is externally defined, sex for her can be an act of compliance that makes consideration of her own satisfaction unavailable. Since her participation then feels like a sacrifice to her, she can easily feel imposed upon by what others may see as trivial irritants or frustrations. Taking the side of her defense in this way, the therapist can agree with her view of herself as self-sacrificing, going on to make the unexpected, but nevertheless conceivable, precise formulation that she is trying too hard to be cooperative. Interpreting from the side of the defense in this way does not require the patient to be reasonable or "motivated," i.e., ready to accept responsibility for the problem.

But how do I know that she really wants to be cooperative? This is, obviously, a common question raised about ego analysis. "Are you saying that we can assume that underneath everyone has these generous impulses?" is one way the question is put. At first this question took me by surprise, since it hadn't occurred to me that I had any such assumption. Ego analysis proceeds from a wholly different assumption, one that actually derives from Freud's earliest insights—that symptoms are inhibited impulses. In this case, the analysis takes off from the recognition that this woman's anger is inhibited. But it is right here that we come to the fork in the road.

I make the point most clearly in the short paper How Id Analysis is Still With Us, that the repression model has generally been misunderstood. This woman has a feeble, even comic excuse to avoid sex with her husband. The id analytic understanding of this is that she really wants to castrate him, but the impulse is repressed. Why? Well, she just won't admit it, maybe because she thinks it's bad, or that other people would and she is sensitive to that. It just is some variant of the idea that repression is caused by a collision with reality. 

But we now know, don't we, that the causes of repression are not to be so casually construed. Cognitive therapy has helped make this clear. From the ego analytic perspective, this woman is unable to want to castrate her husband. Indeed, any such wish is itself the consequence of being unable to be directly hostile, i.e., to really complain—effectively and satisfyingly. So that is how and why I can infer that she would see herself as being self-sacrificing, as putting up with a lot, and that this would have some truth to it. It does not follow that she is really a nice person. She probably isn't, although she probably would be a lot nicer if she was not so easily trapped.

But, people will then ask, "What about patients who really are sadistic, borderline. cruel, etc." My only answer to that is that if it is a symptom, then it is about something, and my analysis would proceed as above. If it is not a symptom, but is essentially ego syntonic, then the only people who need treatment are those this person comes in contact with.

Back to the case. Since intervening in the way I've been describing is an attempt to protect the patient from her inner defensiveness (self-hate), the problem of defensiveness in relation to the therapist is not as great, making regression less likely. Where the unmasking techniques of depth therapy treat defensiveness as an interference with the resolution of the problem, ego analysis takes the patient's defensiveness itself as the heart of the problem.

To summarize the diagnostic implications of my discussion: From the depth-analytic point of view it is the wife's pathological anger that contributes to her husband's impotence. This may be her own nightmare view of it as well and a reason why any hint of such an interpretation could trigger storms of protest. From the defense-analytic or ego analytic point of view we would be more likely to arrive at the formulation that is the wife's repression of her anger—meaning her fear of her anger—that is the primary contributor to her husband's impotence. As a result of this repression, her anger and her complaints could be sufficiently veiled from her husband to make it possible for him to believe that there was a real basis for him to feel aroused by his wife. This would leave him feeling that his lack of response made no sense, meaning there was something wrong with him, creating or reinforcing performance anxiety and impotence.

Following this reasoning, if the wife's anger and alienation were overt and direct it could not contribute to her husband's impotence. It could only turn him off, perhaps conclusively enough to satisfy him that his lack of response was functional rather than dysfunctional.

This wife's fear of her anger and her inability to complain would not require individual therapy to unearth and would not have to be bypassed. Working in this way, from the side of the defense and with a symptom focus, can achieve what have generally been considered long-term goals. Sex therapy cases make especially good illustrations since such patients are typically interested only in symptom relief and have no interest in exploratory or insight therapy. (Of course, it would hardly make sense to them to suggest that the most effective way to accomplish symptom relief is through insight, since insight has come to mean discovering how neurotic you are.)