GLUCKSMAN DISCUSSION OF MASOCHISM AND PATHOLOGICAL GAMBLING

Discussion of Masochism and Pathological Gambling: A Review of Masochism Myron L. Glucksman Richard Rosenthal’s article on “Masochism and Pathological Gambling” (2015) examines the phenomenon of pathological gambling with a special emphasis on its masochistic aspects. In this discussion, I intend to focus on the general topic of masochism, including some comments on Rosenthal’s article. At the outset, a definition of masochism is in order: masochism involves a constellation of fantasies, feelings, ideation, and behaviors characterized by subjectively experienced, selfdirected pain, suffering, guilt, humiliation, or failure that seems unnecessary, excessive, and largely self-induced. Masochistic symptoms and behavior may constitute the central elements of a disorder, such as Self-Defeating Personality Disorder (DSM-III-R; APA, 1987), Masochistic Personality Disorder (Cooper, 2009), Sexual Masochism Disorder (DSM-5; APA, 2013), or may be a significant component of any other type of psychiatric disorder. In this discussion, I shall explore the developmental factors, psychodynamic processes, clinical manifestations, and treatment issues involved in masochism. In his review of masochism, Rosenthal (2015) refers to Freud’s (1924) observation that the masochist has a need for punishment from a parental power. To evoke this punishment, “the masochist must do what is inexpedient, must act against his own interests, must ruin the prospects which open out to him in the real world and must, perhaps, destroy his own real existence” (p. 169). It is noteworthy that Freud made no reference to sexuality in this statement, although his initial observations on masochism were intimately linked to his early theory of sexual development. In “Three Essays on Sexuality” (1905), Freud refers to KrafftEbing’s (1895) description of the term “masochism” that was named after Leopold von Sacher-Masoch, who wrote Venus in Furs (1870). In

Myron L. Glucksman, M.D., Clinical Professor of Psychiatry, New York Medical College, Valhalla, NY; Supervising and Training Analyst, The Psychoanalytic Institute, New York Medical College. Psychodynamic Psychiatry, 43(1) 27–46, 2015 © 2015 The American Academy of Psychoanalysis and Dynamic Psychiatry

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this novel, the hero is subjugated and tortured by a voluptuous, icy woman. Krafft-Ebing (1906) defined masochism as “the wish to suffer pain and be subjected to force, the idea of being completely and unconditionally subject to the will of a person of the opposite sex; of being treated by this person, as by a master, humiliated and abused” (p. 131). In “Three Essays on Sexuality” (1905), Freud postulated that mental life revolved around biologically based sexual instincts. Sadism was primarily derived from the instinctual aggressive drive, and masochism was a perversion that arose from a transformation of sadism and turned against the self. Later on, Freud (1915) further elaborated on the instinctual origin of sadism and masochism, and emphasized that they differed in regard to their aims. That is, “masochism is actually sadism turned round upon the subject’s own ego…with the turning round upon the self the change from an active to a passive instinctual aim is also effected” (p. 127). By the time he wrote “The Economic Problem of Masochism” (1924), Freud had further refined his views on masochism. At this point, he believed that masochism was part of the Nirvana principle and belonged to the death instinct, while the pleasure principle was part of the libido, or life instinct. According to Freud, masochism could be expressed in three forms: (1) Erotogenic, (2) Feminine, and (3) Moral. The first referred to pleasure in pain, and was biological in origin. The second referred to the subject placed in “a characteristically female situation…being castrated, or copulated with, or giving birth to a baby” (p. 162). Unfortunately, this comparison of masochism to feminine-like behavior came to haunt Freud in later years, and gave the diagnostic term “Masochistic Personality Disorder” (Cooper, 2009) a negative connotation. Freud linked the third type, “moral masochism” to an unconscious sense of guilt in which the ego seeks punishment from the super-ego. This form of masochism has its origin in the oedipal complex with its associated guilt and need for punishment by a parental power. At this point, Freud loosened the connection of masochism to sexuality, and stated that “suffering itself is what matters” (p. 165). Although he did not elaborate further on the non-sexual aspects of masochism, he introduced the connection between masochism and the parent–child relationship. Reich (1933) departed from Freud’s emphasis on the instinctual nature of masochism, and viewed it as a defensive protection against oedipal anxiety. According to him, the masochist inhibited sexual pleasure and sought lesser punishments in order to avoid greater ones. Reich viewed the future masochist as a person who was emotionally hurt in childhood and defended himself from further injury by suffering. Horney (1937) took issue with Freud’s concept of feminine masochism, and clearly stated that it was not part of femaleness. She suggested

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that the masochist suffered in order to defend against feelings of intrinsic weakness or insignificance. Bergler (1961) believed that masochism has its roots in the first 18 months of life when the infant is fearful of being starved or killed. As a result, it becomes furious at this assault on its omnipotent wish for control. This fury cannot be expressed toward its mother upon whom it depends, and is therefore directed against the self. Lowenstein (1957) viewed masochistic behavior as a way of avoiding castration and object loss. In response to anxiety engendered by these circumstances, the masochist attempts to seduce the aggressor by suffering. Menaker (1953) emphasized the pre-oedipal origins of masochism, and viewed it as defensive in order for the child to maintain attachment to its mother. Likewise, Berliner (1958) believed that masochism was an attempt at preserving a pre-oedipal object attachment in the face of an unloving or cruel mother. In a similar vein, Eidelberg (1959) thought that the child who experienced narcissistic injuries brought about humiliating situations as an adult. By humiliating himself, the masochist is able to initiate and control masochistic activities. In a seminal paper, Bieber (1953) expanded on the concept that masochism is a defensive phenomenon, and not instinctual. He observed that masochistic acts and attitudes are adaptive and protect the individual against greater or more painful perceived injuries. Although he acknowledged that masochism can be manifested in sexual activities, he pointed out that it is a frequent component of non-sexual fantasies, attitudes, and behavior. Bieber noted that normal sexual behavior (e.g., masturbation) is often prohibited or punished, and therefore associated with anxiety and/or guilt. Oedipal rivalry and the fear of punishment from the isosexual parent may also be a source of anxiety. Masochistic sexual activity localizes and limits these anticipated injuries. The masochistic partner requires, as well as controls, pain and suffering in order to perform sexually. The pain and suffering is not inherently pleasurable, but rather permits sexual gratification. By the same token, the sexual sadist also localizes and controls the pain and suffering of sexual activity in order to experience sexual pleasure. According to Bieber, masochistic attitudes and behavior are primarily defensive in the context of a variety of threats. For example, the fear of antagonizing competitors by winning or succeeding in various activities may lead to self-sabotage. Procrastination, work inhibitions, and feelings of inadequacy are forms of self-sabotage in order to avoid the envy and hostility of others. Pathological dependency may also be a masochistic defense against the threat of a greater injury, such as abandonment. Anxiety, obsessive thinking, and preoccupation with somatic symptoms

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frequently function as masochistic defenses against anticipated injury from others. Such individuals often function better during times of extreme realistic stress (war, natural disasters) because the feared threat is external, can be identified, and responded to. Painful affects, including guilt, self-loathing, and unhappiness may also function as masochistic defenses. Intimate relationships are often sabotaged because of the fear of rejection, abandonment or subjugation. Some individuals elicit love and attention using masochistic techniques such as pain, suffering, and self-devaluation. Hostility always accompanies masochistic behavior toward another person because the latter is perceived as the source of anticipated injury. Bieber’s comments about therapeutic techniques with masochistic patients are worth noting. He stresses identification of the irrational fears and beliefs that promote masochistic behavior (e.g., masturbation is dirty) before attempting to change it. In addition, he reminds us that some self-injurious acts are not masochistic, but instead are self-preservative; for example, cutting off a gangrenous finger, vigorous exercise in preparation for an athletic competition. He notes that all neurotic activity is self-injurious, but not always masochistic. For example, the excessive use of alcohol may be primarily for the purpose of soothing unpleasant affects such as anxiety or depression; obsessivecompulsive individuals may procrastinate completing tasks because they are not perfect. In order for an act to be masochistic, the primary motivation either consciously or unconsciously must be for the infliction of pain or suffering on the self. Although the adaptive or defensive role of masochism was previously described by others, Bieber’s contribution is particularly illuminating. Shainess (1997) commented on the relational significance of masochism. She observed that masochistic symptoms, including low self-esteem, misanthropy, self-abasement, apology, and saccharinity are interpersonal ploys intended to avoid intimacy with others. Moreover, while making the individual appear worthless and inferior, these behaviors maintain superiority and control in relationships. Bonime (1995) similarly observed that suffering, helplessness, and depressive feelings are used to manipulate or control others. He emphasized the competitive nature of masochism, or in the words of one of his patients, “I win by suffering” (p. 34). Kernberg (1988) differentiates between normal behaviors that involve pain or suffering, and pathological behaviors that are masochistic. The former may involve hard work (studying, exercising) that postpones gratification in the service of a constructive goal. According to him, normal erotic excitement may involve mild forms of pain, playful debasement, and humiliation. On the other hand, masochistic behaviors are a frequent component of depressive, borderline, and narcissistic disor-

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ders. Negative therapeutic reactions commonly occur with depressive patients out of a sense of guilt; narcissistic patients need to destroy the therapist because of unconscious envy; borderline patients cannot tolerate the therapist as a good, loveable object and need to sever all ties. Cooper (2009) observes that masochistic traits are attempts to repair the painful, narcissistic injuries of childhood. The masochist reproduces or perceives in his external world the injuries suffered at the hands of the disappointing, rejecting mother. Narcissistic rage is directed at the person or object that has injured the masochist. As the narcissistic rage diminishes, the masochist becomes self-pitying and self-suffering. The over-riding conviction of one’s special plight in life reflects the narcissistic component of masochism. Gabbard (2012) points out that masochists re-create abusive or humiliating experiences of childhood, in order to exert some control over them. He states: “By unconsciously orchestrating the repetition of childhood trauma, they avoid being ambushed by it” (p. 104). Various forms of suffering are used to defend against attacks from oedipal rivals or pre-oedipal traumas. He compares this to the rituals of sacrifice to the gods used in different religions. The belief in the “evil eye” is a manifestation of this masochistic practice found in many cultures. For example, the phrase “break a leg” given to performers prior to going on stage is an example of making a lesser sacrifice in order to prevent a poor performance. The Yiddish expression keyn aynhoreh is used to ward off evil or destructive forces in the setting of good fortune (birth of a baby, financial success). Of interest, Gabbard (2012) also notes that some therapists who engage in sexual misconduct with patients masochistically submit to their patients’ demands and are grandiose in their violation of therapeutic boundaries; for example, “I was sacrificing myself in order that she could live” (p. 105). In summary, psychoanalytic theories of masochism have evolved from Freud’s (1905) early conception of its instinctual origin, to his later observation that it is connected to feelings of guilt associated with oedipal rivalry (Freud, 1924). Subsequent theories have emphasized the adaptive, defensive nature of masochism, as well as the fact that masochistic behavior is often nonsexual. The later theories postulate that narcissistically injurious experiences in childhood sensitize the future masochist to similar or derivative injuries in adulthood. As a means of controlling and minimizing these threats, the masochist engages in self-inflicted pain and suffering that is perceived as a lesser injury than the expected one. An important aspect of masochistic behavior is that it can be employed in interpersonal relationships to avoid injury (e.g., rejection) and to control or manipulate others. As Rosenthal (this issue) notes, there are a variety of determinants to masochistic behavior that

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include: expiating guilt; avoiding a greater pain or injury (loss, abandonment); evoking love or sympathy from a parent or significant other; re-creating a traumatic, injurious experience in order to exert some control over it; manipulating or controlling another person in order to avoid anticipated injury (criticism, abandonment). Rosenthal (2015) devotes the major portion of his article to an examination of masochistic gamblers. He refers to a study (Comings et al, 1996) in which approximately 9% of pathological gamblers report masochistic sexual fantasies. On the other hand, he does not cite any studies that report the percentage of gamblers with nonsexual masochistic fantasies. One of the clinical vignettes he presents is of a male pathological gambler who preferred relationships with women who inflicted pain during sex. He also reported “incredible” sex after a big loss, accompanied by vivid masochistic imagery. The rest of his clinical vignettes are pathological gamblers who are masochistic, without sexual masochistic behavior. This seems to be consistent with the low percentage of reported sexual masochism in pathological gamblers. One of his patients needs to create financial crises and to lose money. Another believes that if he loses at gambling, his father will love and take care of him. Still another is guilty over surpassing his father careerwise, and after each professional triumph needs to go on a gambling binge. The final patient was sexually abused by her father, felt guilty, and did not deserve to be loved. Gambling is a form of punishment, and re-creates the terror, chaos, and pain of her childhood. Rosenthal’s patients demonstrate some of the dynamic determinants of masochism, as expressed through pathological gambling: to expiate oedipal guilt by losing; to suffer financial loss in order to enjoy sex; to win a father’s love by losing; to re-create the traumatic pain and helplessness of childhood in order to gain some measure of control over it. Although Rosenthal uses pathological gambling to demonstrate some of the determinants of masochism, there are a multitude of behaviors, attitudes, fantasies, affects, and relationships that are primarily masochistic. As Bieber (1953) notes, almost all pathological behavior is self-injurious, but not necessarily masochistic. Phobic patients deprive themselves of certain gratifications, but the etiology of their phobias is not necessarily masochistic (e.g., abandonment, loss of control). Substance abusers are decidedly self-harming; however, the reasons for their drug-seeking may not be primarily to punish themselves (e.g., to alleviate anxiety, depression). Suicidal individuals are unquestionably self-harming, yet the reasons for suicide are often not masochistically driven (e.g., despair, revenge). Unfortunately, the differences between masochistic and non-masochistic psychopathology can be muddied, leading to erroneous conclusions about etiology, dynamics, and treatment. In order to

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distinguish between masochistic and non-masochistic psychopathology, I shall present several cases from my own practice to illustrate the differences. The following are case illustrations* that demonstrate masochistic psychodynamics and psychopathology: 1. Ms. B. was a divorced woman who entered treatment for depression, depersonalization, self-mutilation, and suicidal ideation. She was sexually abused by her father from age 6 to 13. Her former husband was an alcoholic, who verbally and physically abused her. Her mother was passive and failed to protect her from her abusive father. She had a long history of cutting herself on her extremities and torso. Her self-mutilation was a way of punishing herself for her incestuous relationship with her father. In addition, cutting enabled her to feel pain, which was preferable to her chronic inner sense of numbness and depersonalized state. She mistrusted men and purposely did not date or have any relationships with men following her divorce. Her early transference to me was positive and idealizing. She felt that I was kind and considerate. However, as treatment progressed, she began to complain about my inability to help her feel less depressed and self-punitive. She repeatedly threatened suicide and her cutting became almost a daily occurrence. During therapy sessions she often remained silent and refused to answer questions. She was vague about her suicidal plans and often kept me guessing about her self-destructive fantasy life. Moreover, she was noncompliant with medication. I found myself becoming increasingly annoyed with her, and occasionally felt like yelling at her or shaking her. I realized that we were engaged in a transference-countertransference re-enactment of the abused child and abusive father. On more than one occasion, she told me that she secretly wanted me to rape her. Serendipitously, my dog often accompanied me to the office, and she found him to be comforting. A split-transference developed in which she felt the dog was friendly and protective, while I was critical and unsupportive. I discovered that she often informed him about her urges to either cut or kill herself while she was alone with him in the waitingroom, prior to sessions. As her split-transference became clearer to me, I pointed out that the dog was a good, benevolent father and I was a bad, cruel one. As time passed, she occasionally criticized the dog (“he’s not friendly today”) and complimented me (“I can always rely on you”). In effect, the split-transference sometimes *Names and details have been changed to protect patient privacy.

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became reversed, where I was the good father while the dog was the bad one. Her struggle with bad and good internalized objects (I and the dog) continued for a number of years. I viewed this as her attempt to re-create a childhood where her father not only sexually abused her, but threatened to kill her if she told her mother about it. In doing so, she felt abused by me, but was able to attenuate it with the protective, friendly dog. Her masochistic psychopathology (cutting, suicidal ideation, rape fantasies) was clearly connected to her guilt over the incest, rage at her father, and the need to punish herself. As she gradually internalized the positive aspects of our relationship (safety, trust, empathy), her masochistic behavior lessened. By the time treatment was mutually terminated, she no longer needed to cut herself and was not suicidal. 2. Mr. G. was a middle-aged, married, corporate executive who entered treatment for depressive symptoms, marital and career difficulties. He reported that his sexual relationship with his wife was almost nonexistent, and that he achieved sexual gratification only by masturbating. His masturbatory fantasies usually consisted of a young boy being beaten or tortured by an older woman. The young boy was either forced to have sex with the older woman, or sometimes with a younger one. On the rare occasions that Mr. G. had sexual relations with his wife, he employed this fantasy in order to achieve an erection and orgasm. He also reported that he had a history of homosexual fantasies, but never acted on them. The masturbatory fantasies were almost always heterosexual, although the young boy was occasionally forced to have sex with an older man. He denied participation in sadomasochistic sexual practices in the past, or with his wife. Mr. G. was a senior executive with other employees reporting to him. However, he found it difficult to assert himself at meetings, and almost never contradicted his boss. He usually accepted criticism from those senior to him, without defending himself. Mr. G. found it difficult to give himself pleasure in non-work related activities; such as hobbies, athletics, vacations, etc. Even though his house had a swimming pool and tennis court, he rarely used them. His mother was a Holocaust survivor who lost her parents, grandparents, and several siblings in a concentration camp. He described her as angry, critical, domineering, and manipulative. However, she adored him, as long as he did what she demanded of him. He had an older sister who was married and living in another part of the country. If he disappointed or countered his mother’s wishes, she became vicious. His father was passive, intelligent, and kind. He never stood up to his wife,

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and instead, retreated to his newspaper and books. Mr. G. had no sexual relationships prior to meeting his wife. She was divorcing when they met, and was the aggressor in their sexual encounters. During treatment, Mr. G. was quite verbal and frequently used humor when the topic under discussion was threatening to him. He complained about his former therapist, an older woman, whom he felt was too opinionated. Because he lived at some distance from me and travelled extensively for his work, it often remained up to him to initiate appointments. There were frequent lapses of time between appointments before he called to make one. At one point in his career, he had a female supervisor who criticized him for being too passive and not taking enough initiative. He identified her with his mother’s critical, devaluing attitude toward him. At another time, he had a male boss who suggested that he obtain coaching to help him assert himself at meetings. It became clear that his masturbatory fantasy was a re-enactment of his relationship with his mother. In order to achieve sexual gratification, he had to submit to an authoritarian female’s torture and abuse. The young boy represented himself, submitting to his mother’s demands and criticism. Sexual pleasure was only permitted when he suffered and obeyed the older woman who tormented him. A similar dynamic occurred between Mr. G. and his wife; she controlled the household and made the important family decisions. When she was angry at him she maintained a cold distance, but he usually refrained from confronting her over it. In “A Child is Being Beaten” (1919), Freud observed that males substitute mothers for their fathers in masturbatory beating fantasies. According to Freud, this is because the son unconsciously wishes for an incestuous attachment to his father, but needs to deny his homosexual object choice and “endows the women who are beating him with masculine attributes and characteristics” (p. 200). In Mr. G.’s case, there was no evidence of homosexual impulses toward his father, although the boy in his masturbatory fantasies was sometimes forced to have sex with an older man. In any event, he consciously perceived his mother as the domineering, punitive parent. Mr. G.’s masturbatory fantasies seemed to increase when he was stressed at work, especially when he felt his boss was too demanding or critical. Of interest, he never reported dreams in which the theme or imagery of the manifest content was sexually masochistic. On the other hand, many dreams reflected his passivity with others. His transference was positive for the most part; I was identified with his gentle, kind father. However, there were occasional manifestations of negative transference; for example, avoiding sessions,

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humorous wisecracks about my vacations. When his mother died, she left her entire estate to Mr. G.’s sister. For him, this was a final act of cruelty. 3. Mr. P. was a middle-aged, married, successful entrepreneur. He began treatment when he became depressed following the death of his young nephew from a brain tumor. His nephew’s death saddened and terrified him. He became acutely aware of his own mortality, as well as the fragile nature of the lives of his wife and children. He became disinterested in the business project with which he was involved, and procrastinated making important decisions related to it. Although he had become quite successful in his chosen field at a relatively young age, he was constantly plagued with feelings of self-doubt, self-criticism, and insecurity. He frequently procrastinated having to make decisions, and found numerous ways to distract himself from whatever important project with which he was involved. Despite these traits, he was considered a success in his field of endeavor by others. Mr. P.’s parents were both retired professionals. He was a middle child, and had an older sister and younger brother. An earlier marriage ended in divorce, prompting him to seek therapy. At that time, he found himself unhappy, confused, and engaged in self-sabotaging behavior. His therapist commented that he seemed to “celebrate” in his self-destructive activities (drinking, drugs, and inappropriate romantic partners). Therapy helped him to become more productive, and he recalled the words of his therapist who emphasized “gratification in the exercise of function.” Subsequent to therapy, he met his second wife with whom he had a son and daughter. Mr. P. was born in Chicago and essentially raised by a nanny, because both parents were professionals who worked. At age four, his parents moved the family to San Francisco and he lost his beloved nanny. In San Francisco, the family moved from one residence to another between ages 5 to 12. His father, who worked long hours, was usually irritable and self-absorbed when he came home. His mother became a virtual recluse, did not work, and was chronically depressed. He felt emotionally abandoned by his parents, and virtually left to his own devices. After school, he played with neighborhood kids who engaged in risky activities (e.g., playing around dangerous construction sites, stealing from stores). Although he knew he was smart, he neglected his homework and on one occasion, deliberately failed a test. He was angry at his parents for not providing him with a permanent residence, sufficient attention, and a stable family life. He felt that he was fraudulent, and pretended to his friends that he belonged to a normal fam-

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ily, when the reality was quite the opposite. At age 12, his parents moved to a small town in New Jersey. Once again, he felt uprooted and uncertain of the future. His parents enrolled him in a military school where he spent an unhappy year in an authoritarian, punitive environment. Following that, he was sent to a private boarding school where he felt like an outsider who did not come from the privileged backgrounds of the other students. While there, he broke rules, smoked pot, and under-performed academically. In the meantime, his parents finally bought a house but failed to furnish it adequately, nor did they take proper care of it. Once again, he felt ashamed of his home and family. His academic record in college was mixed, and he thwarted his parents’ ambition for him to become a doctor or lawyer. Serendipitously, he discovered his current occupation after college, and by all accounts has been extremely successful despite his self-sabotaging behavior. During the course of treatment, Mr. P. became aware that every time he achieved success or experienced a feeling of well-being, he expected that some disaster would occur, taking away his success and good feelings. His catastrophizing and negative ruminations made him feel unhappy and anxious. He associated this fear to the unexpected disasters of his childhood, including the sudden loss of his beloved nanny, the emotional absence of his parents, the lack of a permanent home, and being sent away to boarding schools. In addition, he realized that his academic failures were a form of retaliation and vindictiveness toward his parents. Perhaps, they would finally pay attention to him when they realized the depths of his suffering. The death of his nephew, and the suicide of his brother-in-law several years later, reinforced his view that life was capricious and could be taken away at any moment. In some magical way, Mr. P. believed that his self-destructive behavior might appease the gods and prevent misfortune. Somehow, he needed to atone for the sins of his success by undermining it in various ways. He also believed that his self-image as a successful entrepreneur was essentially fraudulent and inauthentic. His authentic or real self was one that was the product of his childhood catastrophes and dysfunctional parenting. His self-destructive behavior was, in some way, an expression of his authentic self, and a rejection of his successful, yet fraudulent self. At one point during therapy, he asked me for some practical suggestions regarding one of his work projects. Although I did not give him specific advice, I encouraged him to update me on a regular basis about the project. He continued to do so, and the project turned out to be quite successful. I believe this was a

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re-enactment of his childhood experience with his parents, in that he was asking me for the help and support he was unable to elicit from them. My availability and helpfulness was an emotionally corrective experience for him, in contrast to the inattention of his parents. As he continued to gain insight into his self-sabotaging attitudes and behavior, he gradually became more productive at work. His pleasurable experiences and feelings of happiness were not as quickly erased by self-inflicted, unpleasant preoccupations and catastrophizing. He also made a conscious effort to be more emotionally available and responsive to his wife and children. Each of the previous patients exhibited masochistic psychodynamics, ideation, sexual fantasies and behavior. Ms. B. felt guilty over her incestuous relationship with her father and punished herself with selfmutilation and suicidal fantasies. She attempted to re-create her sadomasochistic relationship with her father in the therapeutic triad (self, dog, therapist). This was a safer, more controllable situation than the original one, and was an attempt to bring about a healthier, trusting relationship with a father surrogate. Mr. G. grew up with a domineering, critical, manipulative mother. In order to maintain her love and approval, he needed to submit to her demands. His masturbatory fantasies reflected his need to be mistreated or tortured by a domineering woman in order to achieve sexual satisfaction. Moreover, his passivity and unassertiveness with his wife and superiors were further manifestations of his masochistic defenses. Mr. P. had a number of traumatic experiences growing up, including the loss of his beloved nanny, multiple geographic moves, abandonment to oppressive boarding schools, and emotionally unavailable parents. Unconsciously, he believed that each success or pleasurable experience in his life would be linked to a disaster or disappointment. Consequently, he engaged in masochistic fantasies and behavior in order to magically prevent expected emotional or physical injuries (loss, abandonment, corporal punishment). Procrastination, indecision, and self-devaluation were among his defensive ploys to ward off the capricious or inevitable catastrophes of life. The following are case illustrations that demonstrate non-masochistic, self-injurious psychopathology: 1. Ms. L. was a middle-aged, married woman who entered treatment because she suffered from multiple phobias and anxiety. She was agoraphobic, and afraid to eat a variety of foods. The latter included meat, fish, and vegetables; she believed that she would suffer an anaphylactic reaction if she ate them. In addition, she was afraid

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to frequent public places such as stores, theaters, and restaurants. At the time she sought treatment, she weighed only 92 pounds, and subsisted on toast and fluids. However, her sleep and appetite were within normal limits, and there was no evidence of depression. Her restrictive food intake was unrelated to a compulsive need to lose weight. Her body image was undistorted, and she did not exhibit other symptoms of anorexia nervosa (e.g., amenorrhea). Ms. L. grew up in an upper middle-class family, and was a college graduate. Her mother was alcoholic, phobic, and emotionally repressed. On the other hand, her father, who died five years before she began treatment, was affectionate and supportive. She had a younger sister who suffered from allergies and functional colitis. Her mother paid more attention to her sister because of the latter’s physical problems. When Ms. L. left home for college, she developed typical anxiety symptoms. Her mother interpreted her symptoms as allergic phenomena and sent her to an allergist. She was treated with a desensitization regimen, and improved somewhat. Following graduation from college and her break-up with a boyfriend, she once again developed anxiety symptoms and was treated by an allergist. Subsequent to her marriage, she became increasingly phobic in the context of her husband’s frequent trips away from home on business. She was ultimately referred to me by her internist, who determined that she was neither allergic nor suffering from a somatic illness. During treatment, it became clear that her mother did not allow either her sister or Ms. L. to separate fully from her. Through her manipulative behavior, she kept them closely attached to her. She focused on their somatic symptoms and reinforced their fear of becoming severely ill if she was not close at hand. Ms. L. was convinced that she might suffer from an anaphylactic reaction due to her allergies, and needed to be in close proximity to her mother. Moreover, any kind of independent, assertive behavior on her part was criticized and linked to potential disaster, by her mother. Consequently, she became pathologically dependent on her mother, and convinced that she would become ill or die if she acted independently of her. Her limited capacity to socialize, make friends, and meet her future husband was, in large measure, due to her father’s support and encouragement. Eventually, she acknowledged her feelings of rivalry toward her mother and sister for her father’s affection, as well as her fear of their retaliatory aggression. Ultimately, she made the connection between her murderous wishes toward them, and her fear of death in the form of an anaphylactic reaction. At no point during therapy did Ms. L. indicate, con-

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sciously or unconsciously, that she sought pain, suffering, or punishment. Instead, her phobias and anxiety were manifestations, as well as defenses, against her fear of illness or death linked to individuation and oedipal rivalry. Through a combination of phobic desensitization and psychodynamic therapy, Ms. L. gradually improved. At the time of termination from treatment, she weighed 108 pounds, was no longer phobic, and relatively free from anxiety. 2. Mr. W. was a middle-aged, married artist who entered treatment for anxiety, depressive symptoms, and work inhibition. He was a painter with a history of moderately successful exhibits and sales. Mr. W. was an only child, and grew up in an affluent family. His father was emotionally remote and strict. His mother was alcoholic, moody, and sexually provocative. When she was angry with him, she frequently withdrew and was silent for days. She often appeared half-naked in front of him, and may have fondled his genitalia when he was a child. Mr. W. was sent away to a private boarding school, where he was frequently teased by the other boys for being awkward, fat, and athletically uncoordinated. He recalled feeling humiliated when he dropped a baseball, or ran in the wrong direction during a football game. In the summers, he stayed with his parents at their vacation home in a sparsely populated area. As a result, he played mostly by himself and lacked close friendships with other males. Mr. W. recounted several rebellious acts toward his parents while growing up: once, he took down his pants and exhibited his buttocks at another boy’s birthday party; during his senior year of high school, he deliberately obtained poor grades in order to thwart his father’s goal for him to attend an Ivy League college. He performed fairly well at the college he did attend, and subsequently obtained a graduate degree in fine arts. Following that, he worked as a graphic artist for an advertising agency. Mr. W. was shy with women, and did not have his first sexual relationship until he was in his late 20s. He met his wife through mutual friends, and married her because he felt guilty for having sexual relations with her over a prolonged period of time. She also came from a distinguished family and he felt that her social pedigree would enhance his standing among others. Following the deaths of his parents, Mr. W. inherited a sufficient amount of money that enabled him to quit his job and freelance as an artist. During treatment, Mr. W. frequently complained about his problems with procrastination and indecision. He agonized over his creative projects, and found it virtually impossible to complete a painting unless he thought it was perfect. Prior to his gallery exhibits, he became highly anxious, suffered from insomnia, and fan-

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tasized about the criticism he might receive. He connected this to the humiliation he felt in school, after he made a mistake on the baseball or football fields. In addition, he felt inhibited and selfconscious in social situations where he was afraid of making a mistake or offending someone. His depressive feelings often followed an exhibition of his work or attendance at a social event, where he felt exposed as incompetent and inadequate. He held extremely high standards for himself, and was very self-critical. By the same token, he was critical of others, especially his wife. He frequently engaged in this type of projective identification, where he projected his persecuted self onto others. In this scenario, he felt less vulnerable, as well as superior to the other person. Whenever he felt that his creative work fell short of his expectations, or that he was unproductive, he became depressed. His sexual performance was correlated with his self-image; he was potent when he felt successful at work or socially, and impotent when he was not. His masturbatory fantasies often involved seeing his mother naked, and sometimes having intercourse with her. No doubt, this imagery originated in childhood and adolescence when he actually was aroused by seeing her in the nude. It also had oedipal significance, and exacerbated his fear of punishment from his father. The latter articulated with his ever-present fear of criticism, rejection, and humiliation by others. However, he never reported masochistic sexual fantasies that involved his mother or other participants. Mr. W. was exquisitely sensitive to my opinion of him. He frequently asked me to comment on his work, or wondered about my view of his behavior in a given social situation. In this regard, I believe he was attempting to re-create his childhood relationship with his parents, when he anticipated criticism for his performance. Naturally, he hoped for a more benign response from me. Occasionally, he would interpret one of my comments as criticism or a devaluation of him. Sometimes, he tried to goad me into becoming angry at him by offering his opinion on a political issue that he anticipated was different than mine. Rather than viewing this as a masochistic maneuver, I saw it as another attempt to elicit a less hurtful reply from me than he expected from his parents. Although Mr. W.’s fantasies and symptoms were self-injurious, they were not masochistically motivated. His procrastination, perfectionism, indecisiveness, and social inhibition were primarily defenses against his fear of criticism and humiliation. He did not employ these defenses primarily to self-punish or suffer, but rather to protect him from anticipated injuries.

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The two previous case illustrations describe symptoms, fantasies, and behavior that were self-injurious, but not primarily masochistic. Ms. L.’s pathological dependency and food phobias were her defenses against her fear of illness and death. She did not consciously or unconsciously want to inflict self-punishment or pain in order to gain her mother’s affection; rather, she wanted to maintain her good health and to survive, despite her mother’s dire warnings of disaster. Ms. L. wished to individuate and separate from her mother, but the latter’s predictions of physical illness and possible death necessitated her close attachment to her, as well as her fear of various foods. Although Mr. W.’s irrational perfectionism, procrastination, and social inhibition were self-injurious, they were primarily defenses against his fear of criticism and humiliation. He did not want to primarily inflict pain or suffering on himself to gain sympathy or affection from his parents and others. His rebellious behavior as a child and adolescent was basically vindictive, and a manifestation of his rage toward his parents. His projective identification of his persecuted self toward his wife and others was defensive and bolstered his self-esteem. Moreover, his provocative behavior with me was an attempt to elicit a more benign response than he expected from his parents and others. In summary, both Ms. L. and Mr. W. exhibited psychopathology that was not primarily masochistic, but rather defensive and self-protective. Treatment of the masochistic patient can be challenging, difficult, and frustrating. Distinguishing between symptoms, feelings, fantasies, and behavior that are primarily masochistic and self-injurious from those that are primarily non-masochistic can be a complex task. In my opinion, the cardinal distinguishing feature is that masochistic defenses are primarily aimed at inflicting pain, suffering, or punishment on the self, in order to avoid injury. Non-masochistic defenses, though self-injurious, are not primarily aimed at inflicting pain and suffering on the self. Although all patients engage in resistances of one kind or another, their primary purpose is defensive, even though they may obstruct therapy. For the masochistic patient, the defensive function of resistance is primarily to self-sabotage, as well as to undermine or destroy the treatment. Kernberg (1988) cautions us about the occurrence of negative therapeutic reactions in the treatment of masochistic patients. Negative transference, a key component of negative therapeutic reactions, can be manifested in a multiplicity of ways. These include overt and covert hostility, pseudo-cooperation, noncompliance, non-engagement, provocation, acting-out (including suicide attempts), splitting, intensification of symptoms, and numerous other destructive behaviors. The primary function of masochistic negative transference is to sabotage or destroy the treatment. The masochistic patient will

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facilitate transference-countertransference enactments aimed at sabotaging treatment. The therapist needs to maintain firm boundaries, and avoid being coerced into the role of a sadist during these enactments. Irritation, frustration, anger, impatience, and retaliatory fantasies are common countertransference phenomena that such enactments evoke. As Bieber (1953) points out, the analyst must be neither permissive nor reassuring in connection with masochistic activities and behavior. However, it is paramount for the analyst to point them out to the patient, and to explore their defensive functions. In doing so, the underlying threats and potential injuries can be uncovered. In my experience, the longer the therapist withstands the various ways in which the patient forces him or her to be the bad, punitive object, the more likely the patient will eventually internalize the good, beneficial qualities of the therapist. Nevertheless, interpretation of perceived threats and injuries, along with identification of the defensive function of masochistic symptoms remain central objectives of treatment. However, the therapist’s role as a benign, non-punitive, supportive participant over the course of treatment is equally, if not more important. As Millet (1959) observed, the treatment of the masochist requires “empathy, patience, firmness, flexibility, and critical acumen” (p. 46). In summary, I have outlined the evolution of psychoanalytic theories regarding masochism beginning with Freud’s (1905, 1915, 1924) observations that it is primarily instinctual. Subsequent theories have emphasized the adaptive, defensive, interpersonal functions of masochism (Bergler, 1961; Bieber, 1953; Gabbard, 2012; Reich, 1933; Shainess, 1997). Defensive or adaptive functions of masochism include the following: (1) to expiate guilt; (2) to avoid a greater perceived threat or injury (loss, abandonment, failure, death); (3) to elicit love and attention from a parent or important other; (4) to manipulate or control a more powerful person; (5) to re-enact a traumatic or abusive relationship in the past; (6) to avoid intimacy; (7) to ward off destructive forces or catastrophes in the context of good fortune or success. The cardinal feature of masochistic fantasies, ideation, feelings, and behavior is to inflict pain and suffering on the self. This needs to be differentiated from non-masochistic psychopathology that may be self-injurious, but not primarily directed toward the self. Case illustrations have been provided in order to distinguish between masochistic and non-masochistic, self-injurious psychopathology. Treatment of masochistic individuals is difficult and frustrating. Among the challenges to successful treatment are repeated efforts by the patient to sabotage therapy, including negative transferences, negative therapeutic reactions, and transferencecountertransference enactments that force the therapist into the role of a bad, punitive object. The primary goal of treatment is to identify the

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underlying threats or injuries perceived by the patient that promote masochistic defenses. Equally important is the need for the therapist to remain firm, empathic, and non-punitive. This may enable the patient to internalize the therapist as a good, benign object, and in turn, ameliorate masochistic psychopathology.

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Krafft-Ebing, R. F. von (1906). Psychopathia sexualis. New York: Physicians & Surgeons Book Co. Loewenstein, R. (1957). A contribution to the psychoanalytic theory of masochism. Journal of the American Psychoanalytic Association, 5, 197-234. Menaker, E. (1953). Masochism—A defense reaction of the ego. Psychoanalytic Quarterly, 22, 205-225. Millet, J. A. P. (1959). Masochism: Psychogenesis and therapeutic principles. In J. H. Masserman (Ed.), Science and psychoanalysis, Vol. 2. New York: Grune & Stratton. Reich, W. (1933). Character analysis. New York: Orgone Institute Press. Rosenthal, R. J. (2015). Masochism and pathological gambling. Psychodynamic Psychiatry, 43(1), 1-26. Sacher-Masoch, L. von. (1870). Venus in furs. In F. Savage (Trans.). New York: Belmont Books. Shainess, N. (1997). Masochism revisited: Reflections on masochism and its childhood antecedents. American Journal of Psychotherapy, 51(4), 552-568.

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