Case 28: Assessment and Therapeutic Intervention in Erectile Disorder
The Index client is a 32-Year-old married male, working as an executive in the private sector, living in an urban Indian joint family of high socio-economic status. His family consists of aged parents, his wife and younger sister. He complains about insomnia, excessive worrying, palpitation, constipation, gastroenterological problems, having sad mood, irritability, decreased interest in work, and decreased sexual appetite. All the above symptoms have been ongoing for the past six months. He was referred by his treating psychiatrist for psychological assessment. He took the online SIT in February 2023.
The client has been living with his parents and working from home for the past three years. He always remains under pressure to complete his daily office work and feels tense and anxious. One month back he was transferred to another state. His symptoms aggravated after this, and he started losing interest in work. He got married seven months ago and does not want to live away from his parents and wife. His aged parents also do not want him to relocate at this stage of life.
He started feeling irritated even on small issues. He is under stress from the financial responsibilities of family and his younger sister who is studying abroad. It is discovered later that he is tense and anxious because he is not able to have an intimate relationship with his wife, although he had been sexually active two years back, before marriage, with a girl where he did not face any problem with her.
Results and Discussion:
A few clinically significant responses projected on the SIT are interpreted following Content analysis/ Symbolism / psychoanalytic interpretation:
Image 1. “Bisection of heart”. The response indicates “separation anxiety” because he is getting separated from his loved ones. His transfer to another state may cause separation anxiety. This is confirmed from his case history.
Image 2: He has given two responses on this image (a) “Microscopic image of molecule” and (b)” Phoenix rising from the sky” which may indicate some issues with intimate relationships. The phoenix is a symbol for male genitals and rising from the sky might indicate his desire to feel erotic impulses. He confirmed during inquiry that he is not able to have a relationship with his wife because of erectile difficulties.
Image 3: “A cartoon laughing at me”. The response may indicate a kind of bullying. Another interpretation may be that it indicates paranoid ideation. The client expressed his sufferings of bullying and a kind of humiliation during his school days by his classmate.
Image 5: In this image he has given two responses: (a) The first “A fat girl doing seductive dance trying to seduce me by bending her body”. This response indicates that he does not hold any desire for his partner. The second response was “Two snakes facing opposite directions”. Perception of “Snakes facing opposite direction” may further indicate unpleasant love relations as the snake symbolizes male phallic organs. During enquiry, the client revealed that he is not able to have physical relations with his wife.
Image 6: “Two women, one is leaving and the other one is holding hands so that the first one does not get away”. The response indicates his desire to live with his partner. During the intervention he expressed his fear of losing his wife because of his sexual incompetence.
Image 9: “Two birds joining their beaks”. The response of birds joining beaks is a normal response, but he did not see the birds in action - kissing or playing, which may indicate superficial relationship with his partner. Normally healthy people see two birds kissing in this image.
Image 15: “A deep crater in the ground which is very deep and dangerous”. The response “deep and dangerous crater” symbolizes the female phallic part and may indicate severe sexual anxiety. This may also indicate rejection of the adult role (Schafer,1954), which is clear from the case history of the client. The client verbalized his problems of sexual incompetence.
Image 19: “A mother playing with her baby, she is saying something in his ears and the baby looks angry”. Father and son are the most common responses in this image. Instead of seeing a male figure he has seen a female and rejected the main theme which may indicate “Oedipus complex and fixation in the Phallic stage”. Rejection of perceiving father-figure in this image may further indicate aggression towards him with poor interpersonal relationship. This needs to be probed further and resolved during therapy sessions.
Image 21: “Spider-like creature with tentacles, and a big blue eye on top, it is collecting hearts”. The response of the spider collecting hearts is indicative of wishful thinking to have joy and pleasure with someone else. The blue eye on the top may again bring his paranoid ideation and fear to lose his partner.
Image 22: “Artwork of the heart, and the border looks like pretty petals of roses”. Seeing the heart is the normal response in this image. Seeing “pretty rose petals” might be indicative of wishful thinking of romance with his wife. It may also symbolize “feminine identification, and masculine inadequacy in men (Schafer, 1954). He fantasizes pleasant feelings with two of his past friends while trying to enjoy physical intimacy with his wife. Psychodynamic psychotherapy was administered for conscious anti-cathexis, with positive results.
Image 23: “Looks like “Dildo kept in tight space”. The “Dildo” is the normal response on this image but the “Dildo kept in tight space” may indicate sufferings and painful situation with unpleasant intimate relationship. Snake, spine, missile, sailing boat in sea/river, may indicate symbolic Freudian connotation of male phallic organ.
Image 25. “Broken handle of walking stick”. Broken handle of stick may indicate some issue in genital area, sexual conflict, inability to perform, which must be enquired during therapy session. He confirmed that he has anger towards the one who bullied him during school days. Another interpretation of broken stick may be damaged/incapable male phallic organ, as the stick symbolizes Male Phallic organ.
Image 28. “A mother and a baby. Mother is picking up the child from the floor”. It indicates affection, care and a good interpersonal relationship with his mother. He confirmed that he loves and respects his mother very much.
He has given four Sex responses on images not imbedded with sexual structure. This may indicate high sexual fantasies and desire of intimate relationship. Avoidance of perceiving sexual content on images embedded with phallic regions may indicate deep-rooted sexual conflict. Patients of sexual incompetency often project such protocol. It is clear from the case that he has a very smooth relationship with his mother and has high regards for her. He has also expressed high regards and love for his wife as he says that she belongs to a very rich, highly respected family and brought plenty of marriage gifts including land property from her parental home. All this fits with the Freudian concept of Madonna-Putana Complex (Kaplan, and Sadock, 2015) which may lead to impotency.
Another interesting factor in this case is that his wife is not very good-looking, still he says that he loves his wife. Further he expresses that in response his wife loves him more than he loves her. This unexpressed conflict in the form of love and respect on one side, and rejection because of her physical unattractiveness on the other side may lead to such psychological defenses. He has also expressed during therapeutic intervention that he had a successful physical relation with a female whom he degraded.
Conclusion:
The SIT images helped in understanding the psychopathology of the symptoms and brought to the surface many pleasant and unpleasant memories such as fantasies of two female friends, bullying in the school, conflicting relationship with father and dissatisfied intimate relationship. The images helped in hearing the inner cry of the client. He felt much relieved after the discussion with the therapist. A few sessions of psychotherapy helped with positive results.
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