1 JSS Medical College and Hospital, JSS Academy of Higher Education and
Research, Mysuru, Karnataka, India
2 Columbus Hospital, Hyderabad, Telangana, India
Sona Kakar, Columbus Hospital, Hyderabad, Telangana 500016, India.
Integrating Cognitive Restructuring
Within Psychodynamic Therapy for
T. S. Sathyanarayana Rao1 and Sona Kakar2
The behavior of a human being in sexual matters is often a prototype for the whole of his other modes of reaction in life.1
Erectile dysfunction due to psychogenic cause has been a highly researched area. Psychoanalytically, it has been seen as a
symptom of an underlying conflict due to early developmental experiences. The attitude of parents especially at the time of
a child’s emerging sexuality is considered important in perpetuating sexual inhibition and symptom. Sexual dysfunction has
been found to be closely linked to anxiety and guilt and fears of punishment. This pattern of disturbance permeates into
other areas of a person’s life and may continue to perpetuate his symptoms. Negative body attitude and shame have been
found closely linked to sexual dissatisfaction. In this paper, a case is discussed where a patient is undergoing psychodynamic
psychotherapy for depression reported along with erectile dysfunction. Distorted cognitions related to his and the partner’s
body were addressed along with both current and past conflicts related to his current symptomatology.
Sexual dysfunction, psychodynamic psychotherapy, cognitive restructuring, body image
Journal of Psychosexual Health
1(3–4) 277–279, 2019
© 2019 Karnataka Sexual Sciences Academy
Reprints and permissions:
Erectile dysfunction has been an area of much research and
debate. The psychogenic cause continues to be a contributing
factor in a majority of younger population presenting with the
problem. Studies have shown that the relationship between
body shame and sexual pleasure and problems was mediated
by sexual self-consciousness during physical intimacy.2 The
problem when experienced in relationships can encompass all
other areas of functioning of a person’s life as well. Cognition
as well as conflicts both are known to contribute toward
perpetuating the problem. Therefore, cognitive restructuring
in therapy aimed at improving relationship difficulties may
help to improve sexual dysfunction in men.
Negative Body Attitude and Shame
Body image self-consciousness during physical intimacy
indicates an internalized process where people are
consequently prone to heightened awareness of how one’s
own body appears to others.3 A mechanism through which
negative body attitudes might be linked to sexual
dissatisfaction can be found in Fredrickson and Roberts’
objectification theory given in 1997. Objectification is the
experience of being treated as a body, predominantly valued
for one’s usefulness to others. Shame is a distressing
emotional state that arises out of negative evaluation of
oneself when compared with a personal or societal ideal.4
Sexual traumatization, such as childhood sexual abuse, seems
particularly relevant to one’s attitude toward one’s body.5
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278 Journal of Psychosexual Health 1(3–4)
Cognitive Interference and Sexual
Initial research focused on the relationship between cognitive
distraction and sexual dissatisfaction, and found that sexual
dissatisfaction was positively related to cognitive
interference.6 Subsequent studies looked closely at cognitive
interference to differentiate between performance-based
cognitive distraction and appearance-based cognitive
distraction, though both were positively related to sexual
A young male, married for 2 years with no prior history of
any psychiatric illness enrolled in therapy for depression. He
stated that he was losing opportunities at work as others at his
office were more outgoing and dynamic and he wasn’t. He
felt defeated and unmotivated and kept thinking of quitting
his job. He claimed that though his colleagues treated him
well, he found he would get angry over a lot of things. He also
found himself procrastinating. He felt worthless and sat the
whole day doing practically no work. He complained of
backache on and off for over a year.
His wife had recently joined him after taking a transfer to
the same city. He complained of occasional arguments with his
wife though he reported that she was quite accommodating.
He complained of erectile dysfunction for the past 6 months.
Although initially he had taken pharmacological treatment
and observed an improvement, it did not sustain and he
currently experienced the same symptoms. No organic cause
was reported. When asked what he would like to work upon,
he stated that it was his anger and depression.
During the fth session, he looked uninterested and
tired. As is customary, the therapist asked him what was the
problem, and if he would like to work upon? He said that
he was not planning to come but came nevertheless. Also,
given that he is tired he nds it difcult to be emotionally
present for any therapeutic work. Noticing the aggravation
of his symptoms in the therapy room, the therapist began to
work toward handling the resistance.
Therapist: I notice you look tired and distracted (pointing
out the resistance).
Patient: Yes, I felt like calling you today to cancel the
session, but then I came.
Therapist: I see. So, you didn’t call me or talk to me,
but bore the difculty (showing how he suffers alone by not
sharing). Why did you not call me?
Patient: I thought you would be disappointed by me
Therapist: What kind of a relationship will it be where
you have to hide what you want and continue to suffer, to
please others (showing him the price of his defense of
avoidance and silence).
Patient: A bad one. Actually, that’s what happens at work
too (gaining awareness). I have been put into a new project
and my team lead keeps telling me that I should discuss my
problems with her, but I don’t. Later I can’t gure things out
because it is new to me. Then she reprimands me in front
of others. Actually, she told me on multiple occasions to
approach her to discuss any problems.
Therapist: What is the reason you don’t ask for help?
Patient: She will judge me. She will think I pretend to be
good, but I am a failure (projection).
Therapist: And here with me there is a thought that you
might think I will be disappointed by you (moving into the
transference to work through the resistance).
Patient: Yes, and that I have so many issues.
Therapist: Is it not what we are here to do? To work
together so that we can share the burden of your problems
and help you with them (inviting collaboration).
Patient: Ah yes, of course! If I don’t tell my problem it is
pointless coming here (more awareness).
Therapist: So, what is the problem you nd difcult to
take help for?
The patient then stated that the problem of erectile
dysfunction for 6 months was the major reason he felt
demotivated and depressed.
A detailed assessment was done regarding emotions,
anxiety, and cognitive interference during sexual activity.
He reported thoughts signicantly related to body image and
cleanliness, both pertaining to himself and his wife.
He reported that his thoughts of himself were “having a
belly, not a t body, bad breath, smelling of sweat.”
His thoughts about his wife were “unsmooth skin,
patches on skin, too much weight on the sides.”
Distracting thoughts were also fantasies related to other
women with perceived smooth skin. He stated feeling angry
toward his wife at these moments and losing interest.
Differentiating Reality From Thoughts and
Therapist: Could your fantasy and thoughts be hurting you. It
seems that every time you want to get close to your real
partner, this fantasy partner pops in. Obviously, since it is
fantasy you can only have a fantasy relationship with her but
then your real relationship will suffer, and you and your wife
will never be able to get close to each other.
Patient: That’s true. Since a very long time I dreamt of a
women with a smooth skin. My parents were very orthodox,
and when most friends were interested in girls, I was expected
to study. I used to watch my friends talking so easily to girls
and it felt like failure. My cousins used to call me “shorty.”
My mother compared me to my elder cousin who was a better
personality and it made me feel I had a weak body. I started
thinking I am unattractive.
Rao and Kakar 279
Therapist: So what words describe you?
Patient: Failure, weak, bad, underachiever, unattractive.
Therapist: If these are the thoughts that come to your
mind to describe you, how are you going to feel (showing
him how he punishes himself)?
Therapist: So how true are these words (exploring
Patient: Not true really. I have always done well and
achieved much. My wife thinks I am attractive. I can see I
have been beating myself up, because this is what is stuck
in my mind since childhood. Possibly, I did not even try
for a relationship because I feared failure (displaying good
Therapist: And so a fantasy became your best relationship
when you did not have a real one. But now you have a real
partner, and you say she is accommodating, but looks like you
still have the fantasy partner between the two of you.
Patient: Looking perplexed that means I have to give up
on my fantasy?
Therapist: The good news is that there is no law which
says that you have to give up on your fantasy. You can hold on
to the fantasy, but every time you open the door, reality will
pop up to disappoint you. Or you can accept the reality and
have a real relationship.
Patient: That makes sense. Actually, my wife is quite
accommodating and fullls a lot of my requests. She must be
feeling so bad, and it makes me guilty. In fact, she was very
patient and understanding about my problem.
Therapist: So what do you feel toward her?
Patient: A lot of love for not judging me. I feel a lot
The patient reported no erectile dysfunction at the next
session. He felt he could talk more openly to his wife and she
was happy that he had begun sharing with her.
In approaching a case of psychogenic erectile dysfunction
multiple variables come to play. These include body
consciousness, cognitive distortions, cognitive distractions,
sexual fantasies, shame, and guilt. Distortions of beliefs and
convictions about sexuality are established in childhood as a
consequence of adverse influences on sexual development.
Destructive attitudes are usually exerted by not only parents
but also other power figures in and outside the family.7 These
attitudes may continue to affect other areas of his adult
functioning perpetuating his distress. These may also add an
element of resistance to intimacy in real relationships.
The role of psychodynamic therapy in working through these
conflicts may continue to be an adjunct to the cognitive
behavioral approach or other therapies in treating erectile
A very signicant factor also includes the attitude
of the partner in handling the shared sexual disturbance.
Since intimacy shared between partners is both sexual and
emotional, a compassionate attitude from the partner may be
vital in treating erectile dysfunction.
Declaration of Conflicting Interests
The authors declared no potential conicts of interest with respect to
the research, authorship, and/or publication of this article.
The authors received no nancial support for the research,
authorship, and/or publication of this article.
T. S. Sathyanarayana Rao https://orcid.org/0000-0002-5727-944X
1. Freud, S. Sexuality and the Psychology of Love. New York, NY:
Simon and Schuster; 1997.
2. Sanchez DT, Kiefer AK. Body concerns in and out of the
bedroom: implications for sexual pleasure and problems. Arch
Sex Behav. 2007;36:808-820.
3. Dove L, Wiederman MWN. Cognitive distraction and women’s
sexual functioning. J Sex Marital Ther. 2000;26(1):67-78.
4. Cohen TR, Wolf ST, Panter AT, Insko CA. Introducing the
GASP scale: a new measure of guilt and shame proneness. J
Pers Soc Psychol. 2011;100:947-966. doi:10.1037/a0022641.
5. Beiber I. The psychoanalytic treatment of sexual disorders. J
Sex Marital Ther. 1974;1:5-15.
6. Beck JG, Barlow DH, Sakheim DK. The effects of attentional
focus and partner arousal on sexual responding in functional
and dysfunctional men. Behav Res Ther. 1983;21(1):1-8.
7. Beiber I. The psychoanalytic treatment of sexual disorders. J
Sex Marital Ther. 1974;1:5-15.