From the author: Summary of the second day of the seminar "The inseparable nature of love and aggression" by Dr. Otto F. Kernberg, organized by the International Psychoanalytic Center on Karpovka. Psychodynamic model of the affective components of the sexual drives Freud proposed a model of two drives - Eros and Thanatos - as oppositely directed conflicting forces. He explained the origins of libido by the ability for erotic stimulation of certain zones - mucous openings and skin, where the idea of ​​erotic objects is primarily formed. For Freud, drive is more of a theoretical construct, a sum of affect and representations. The result has been a contradiction between supporters of the drive theory and those who want to abandon it. Kleinians and Ego psychology, the French school are for its preservation, but supporters of the object relations school reject it. In clinical practice, we see that the drive theory is more often confirmed. Freud was not a psychiatrist, he was a great neurologist, his book on aphasia is still relevant. He became a hostage to contemporary neurobiology, while at the same time refusing to correlate his theory with it. Piaget was the first to suggest the primacy of affect. Freud, on the other hand, proceeded from James-Lange’s ideas about affects as a physiological discharge of excitation. Only in 1929 did McDougall propose that affects be considered an innate primary motivational force. Modern ideas are based on affective neurobiology, as in the works of Pankseepp J., who also assert the primacy of affect in motivation. He describes 6 motivational affective systems: 3 positive (attachment, play, eroticization), 2 negative and neutral (alert system). System attachment is activated in the mother-child dyad, and is responsible for the success of any relationship, play is responsible for social communication not related to attachment, erotic also exists from birth, but needs to be developed and reactivated under the influence of contact with others. The attachment system is also responsible for the ability to care for oneself and the Other, the play system serves the purpose of activating interest, the erotic system is responsible for sexual arousal, and all together they constitute the content of what Freud attributed to libido. Two negative systems are the fight (attack)-flight system, or the separation-panic system. The fight (attack)-flight system marks all dangerous and unpleasant stimuli. The separation-panic system is associated with situations of threat to survival, with a feeling of helplessness and passive suffering. This is a paralyzing feeling of loss and helplessness, which cannot be changed in any way by activity; in children this is observed with the sudden disappearance of the mother, or we can observe its activation in adults, in the case of the experience of vital helplessness in a situation of sudden and intense threat to life. Freud's Thanatos is a combination of these two systems. Freud's drive theory refers us to the innate components of these systems, for which both the brain representation and the mediator systems that supervise them are now known. Already in the 30s, the English analyst Briley noted that when we talk about drives, we are talking more about the specific affects that accompany them. The final system in Panksepp's classification, the alert system, encourages us to seek out pleasurable stimuli. It also determines the search for negative stimuli, from which it is better to stay away. Neuroanatomically, these systems are represented in the area of ​​the limbic brain and amygdala. Activation of impulses occurs from lower levels (hypothalamus food, escape) to higher ones. Cognitively, the impulses of these systems are contextualized in the prefrontal and preorbital cortex. Oxytocin activates the attachment system, the pleasure of feeding, and is equally responsible for the romantic components of erotic desire. Testosterone activates the attack-flight system, aggressive components of desire, the desire to penetrate the Other, painfulpleasures of sex. Oxytocin is involved in arousal, dopamine is involved in experiences of sexual pleasure and the search for an object of pleasure. In the attack-flight system we see complex affects of anger, fear, and envy. The erotic system is responsible for the stimulation of the skin and mucous openings, their ability to respond to pressure and reactions to friction. The long absence of the mother leads to a decrease in the intensity and extinction of child masturbation. Laplanche and his followers and colleagues noted that the mother unconsciously sexually stimulates the baby, activating the child’s erotic system, which contributes to the perception of her as an object of desire, and the desire acquires a specific object. Excitement directed at the mother is characteristic of both sexes, but in girls it is inhibited. The intermittency of the relationship with the mother is also important, when she appears and disappears (“day” and “night mother” in the terms of French authors). Therefore, sexuality takes on the quality of teasing, with the promise of satisfaction. This is clearly visible in the example of excitement at the sight of gradual exposure during striptease. Meltzer describes erotic arousal towards the mother's body as the primary aesthetic source of the perception of beauty. Women are aroused when they are looked at, this is the result of identification with the mother, while men are more aroused when they themselves look, a more voyeuristic component is inherent in them. This whole development is complicated by two additional aspects. The first aspect is the frustration of early attachment to the mother, when negative systems dominate, an early shift of attraction to the father occurs. This leads to the formation of male homosexuality, or a serious inhibition of sexual arousal. Also, in the presence of an overwhelming dominant mother, the desire is inhibited, which we see in the case of severe pathology. In the early relationship with the mother, the baby discovers eroticism in the form of the desire to see the mother, the desire to be seen, the desire to suck and bite the breast as a prototype of merging with the mother and penetration into her. And another early childhood process is the internalization of object relations in the form of the integration of a rigid separation of absolutely good and absolutely bad objects. Any affective interaction with the mother leads to the formation of affective memories stored in the hippocampus. These are the internalized affective traces of dyadic relationships. There is a separation of good and persecutory objects in affective memory. Gradually these aspects are integrated, resulting in a holistic integrated self and other people. Gradually, the mother is perceived as a separate object, located, moreover, in connection with the father. Erotic impulses become directed towards the parent of the opposite sex and rivalry with one’s own parent. Rivalry is ambivalently combined with the desire to obey and imitate, admiring the parent. Feelings for parents of the opposite sex are also ambivalent, since unsatisfied desire itself gives rise to frustration. In the case of normality, ambivalence is tolerable; in pathology, splitting is preserved. This process is influenced by the genetically determined hyperactivity of the negative affect systems caused by a lack of serotonin. Then, let's say the boy retains the split between the ideal and the terrible mother, and he will always look for the ideal woman. Envy of the parent couple also persists. Normally, a child strives to violate the intimacy of the parent couple. But his parents prevent him from doing this. This desire determines pleasure when observing a couple copulating. The desire for public sex and exhibitionism is then determined by revenge. Stoller, studying porn actors, discovered serious childhood sexual trauma in their anamnesis. Under optimal circumstances, learning the personalities of parents leads to the development of the ability to admire them, and also to the capacity for mature idealization. This process ends in adolescence, when the superego matures, and the need arises for separation and redirection of attraction outside the family. Accordingly, a teenagermust overcome infantile prohibitions on sex. Failure to do this leads to serious pathology. One of the characteristics of mature sexuality is the ability to fall in love, the structure of which has a strong passionate component. We are talking about the sum of erotic arousal, affection and admiration for the Other. If this desire is satisfied during adolescence, it creates the conditions for openness and freedom of expression, as described by Bataille. The experience of early aggression from the mother has an even more severe effect, it damages the quality of life even more seriously than oedipal inhibition. This leads to severe disorders of the neurotic borderline, narcissistic and even deeper levels. DIAGNOSTICS OF THE ABILITY FOR LOVE RELATIONSHIPS It is worth asking questions about sexual and love relationships differently to a teenager and a 40-year-old person, but if already at 20 years old a person, when answering questions about whether he loved someone and answers “I don’t know!”, this already indicates a problem. Also, if all cases of love are not reciprocal, or the patient was not interested in love at all. Every person interested in love will normally always find a partner, always, at any age. If the partners are supposedly not the same all the time, this is also his problem. If the orientation is not clear, then the study of masturbatory fantasies and sexual dreams helps. If we see constantly changing preferences, it is worth paying attention to problems of identity. Now about the problem of perversion or paraphilia, as they are now called, since the term perversion is read pejoratively. We are interested in questions of sexual arousal, whether it increases during sex, and whether orgasm is achieved in this process. Joyce Mac Dougall, an analyst of the French school, points out that sadistic, masochistic, voyeuristic, exhibitionistic, fetishistic and hetero-homosexual aspects of sexuality are present in the structure of normal sexual arousal. These elements become problematic if without them it is impossible to achieve orgasm. Thus, one patient could achieve orgasm only by wringing her hands, realizing masochism, and another patient received orgasm only by sniffing a woman’s shoes. He idealized his fetish so much and deified this particular form of sex so much that I already began to doubt myself). The severity and prognosis of perversions or paraphilias depends on the structure of the personality. But sadistic perversion is almost always dangerous to life and health. The best prognosis is at the neurotic level, for borderline people it is more difficult, and it is quite difficult to achieve the effect in narcissistic or antisocial individuals. Sometimes we see cases outside of human interaction altogether. Thus, one of the patients experienced orgasm only when a woman defecated on him during his masturbation. For this purpose, he had a special toilet built. Another, an antisocial patient, achieved orgasm only by masturbating on the roof while throwing stones at women. This case in psychotherapy generally has little cure. Persons with a neurotic level have a favorable prognosis. I had such a patient, a quite pleasant humanities professor, he had a sadistic perversion. He only got an orgasm if he rang the doorbell in a special way, and his girlfriend greeted him at the entrance on her knees and had to suck his dick while tied up and immobilized. This was the only way he could get an orgasm. After sex, they drank tea together, talked about life, and went to the theater, he advised her about life. But since everything here is isolated, the prognosis is good. I repeat, if the partners in a couple can realize this, and it requires mutual pleasure and they are satisfied with it, these are elements of the norm. We ask questions about the coincidence of sexual practice and masturbatory fantasies. Does this happen in real life or only when watching pornography? Pornography is generally quite normal, but people who spend a lot of time watching pornography often have problems. Often this is an attempt to escape from problems in reality. One of my patients with a narcissistic organization who has sexualpromiscuous and often having sex with at least two women in one day, spends a lot of time online doing this activity. Behind this lies, in my opinion, a desperate attempt to find satisfaction. The most common problem is sexual inhibition, and some patients create such an asexual atmosphere that the therapist forgets to ask about it during the structured interview. For diagnosis, the therapist's ability to countertransferentially diagnose is important, how much the patient emits sexual waves, whether he is trying to be attractive or not, arousing or not. The therapist must be open and free to assess the client's sexual attractiveness. The therapist himself may have forms of inhibition associated with social taboos, for example in the form of not noticing sexual provocativeness or inhibition in teenage girls. Young therapists will not be able to appreciate the sexual attractiveness of a 70-year-old woman due to oedipal inhibitions; a masochistic female therapist may experience sexual inhibition in relation to narcissistic, potentially exploitative men. Qualities of a therapist necessary to work with sexual problems: First, it is important to imagine how the patient would live if not having this pathology? This is necessary in order to notice those places where there is inhibition that prevents the client from revealing the potential. It is also important to present this in relation to sexual life, which requires the therapist to be able to have some kind of sexual freedom. It is ideal when the therapist has a full and satisfying sex life. This is also the internal freedom to transfer fantasies in relation to the patient, without reacting them with the patient in actions on the one hand, and without inhibition, on the other, in order to be able to use fantasies as a diagnostic tool of countertransference. Here is an example from my practice: when I was still studying , I had a young patient whose father had recently died, in deep mourning and depressed after that. She had a deep neckline, and I tried not to look there. She moved to another country and wrote me my letter, where she admitted that she had erotic feelings, but she would never admit them to me, because she saw that I was not the person with whom this could be discussed. But I felt it, but didn’t bring it into contact with her! Now I always pay attention to such signals and discuss them with the patient, paying attention to the contradictions: “... although you are in mourning, you are wearing a dress with a neckline, what are you trying to tell me with this?” Answers to questions from the audience about diagnosing gender identity diffusion: Problems with core gender identity cause difficulties in choosing a partner, further confusing the person. Such people are seriously unhappy, having conflicts between their physical appearance and their own desires. Surgeries and hormonal therapy are relatively helpful in such cases, otherwise they suffer from difficulties in sexual behavior, choice of social group, otherwise be on guard. etc. In other cases, when a person suddenly changes his core gender identity, we are talking more about severe diffusion of identity, combined with dipole or pre-detailed inhibition of sexuality, in this case it is important to treat severe personality pathologies. An example of unsuccessful therapy: a 45-year-old man, homosexual, dressed in women's clothing as a transvestite. He was extremely successful as a transvestite, he was chosen, but he wanted to become a woman. As a result of surgery and hormone therapy, he became a woman. After this, he began to feel the lack of his penis, had an aversion to the vagina and became depressed. While he was suffering from depression, no one wanted to operate on him. We tried to treat him at our institute with antidepressants, and I personally took a course of intensive therapy. It turns out that he suffers from a severe narcissistic disorder, and would like to belong to two sexes at the same time, envying the capabilities of each of them, and hating women for their capabilities. Basic.