Abstract
This book presents the accounts of the psychoanalytic treatments of four individuals who seem to seek out pain in their relationships with others and who also cause others pain. Their intense sadomasochistic fantasies and modes of relating were played out with their analysts, whose experience with these patients the editors characterize as “battling the life and death forces of sadomasochism,” a phrase they have chosen as their title. The four psychoanalysts who present their cases—Paula Ellman, Nancy Goodman, Andrea Greenman, and Richard Reichbart—have for many years shared their experience with difficult cases with one another, finding help in a safe setting and in being able to discuss the painful countertransferences that inevitably arise with such cases. Here the cases are presented clearly, without jargon and with extraordinary openness, each followed by discussion by four sets of distinguished analysts: Alan Bass, Jack and Kerry Kelly Novick, and Marianne Robinson; James Grotstein, Margaret Ann Hanly, and Terrence McBride; Steven Ellman, Shelly Rockwell, and Léon Wurmser; and Sheldon Bach, Harriet Basseches, and Leo Rangell. Clinicians who read this book will be able to identify similar struggles and experiences and will find inspiration, help, and hope in these analysts’ work and in the variety of ideas raised by the discussants.
In their introduction the editors outline themes and issues that run throughout the cases: all have issues of control and struggle with conflicts around domination and submission; all wrestle with affect regulation or, as the editors put it, “too muchness” (p. 5). Their lives revolve around basic struggles between the forces of life and death or, in other terms, Eros and Thanatos, living and dying, libido and the death instinct, love and aggression. In accordance with Chasseguet-Smirgel’s depiction of perversion as an anal universe (1991), the editors believe that struggles originating in the anal phase or toddlerhood give sadomasochism its shape in the mind and in interactions with others. This emphasis ensures that their understanding is grounded in drive theory, with a tilt toward aggression. At the same time, one is struck by the intermixing of object relations and psychosexual developmental theory shown by all the contributors. In fact, one of the discussants, McBride, stresses the absolute necessity of multiple perspectives, both theoretical and technical, when dealing with such difficult and complex cases.
To my mind, the transitions between the differing theoretical frames of reference may not be as smooth as the editors suggest. For example, citing Freud (1919), the editors and other contributors, notably the Novicks, suggest that the beating fantasy is central to the understanding of sadomasochism: in libidinal terms, the beating fantasy may “stimulate withdrawal of cathexis from the traumatising object” (p. 20); in different language, however, it can also be understood as a way of attaching to the other. These two differing explanations do not rule each other out, but they are based on different frames of reference.
The four analysands, whose treatments were long and arduous, were on the surface very different from one another. Diane, a former athlete and extreme perfectionist, abused her body so badly she crippled herself. She seemed to feel that there was no room for her own needs and that separateness from others was intolerable. Mr. B, characterized in terms of “hurting love,” searched for perfection in women and rejected every woman with whom he had contact (including, of course, his analyst). Mariah, a lifelong bulimic, was totally consumed with the surface of her presentation to the world and was prone to debilitating panic attacks. Mr. A was described as “tight as a drum,” withdrawn from people and frightened of the world. He was preoccupied with lurid, vengeful sadomasochistic fantasies and had a history of transvestism. (I cannot help but note that the two female patients are called by their first names, while the two males are called Mr. A and B.)
Consistent with other contemporary understandings of sadomasochism (Glick and Meyers 1988; Holtzman and Kulish 2012), much of the underlying psychopathology and personality structure of these patients appears to reflect problems in early object relationships and with narcissism, affect regulation, and aggression, as well as a history of trauma. For example, Bass and the Novicks highlight the function of suffering as a means of attachment traced to an original sadistic object, while Steven Ellman stresses the narcissistic issues underlying sadomasochistic defenses. Most of the discussants agree that the underlying pathology and fantasy structures are primitive, often with anxiety that rises to fear of annihilation (Hanly, Bach), a fragmented sense of self (Bach), and problems differenting self and other (Rockwell). Bach also elaborates how sadomasochistic fantasies are needed in order for the patient to feel alive. Only Rangell disagrees, stating that the case of Mr. A is not one of sadomasochism at all; rather, he is a severe lifelong neurotic whose overt sadomasochistic fantasies and perversion are reactions to an unconscious fear of homosexuality.
There are few references to oedipal issues in this volume, which places it at some distance from Freud’s model of masochism (1919). To be sure, many of the analysts and discussants here refer to primal scene fantasies in their understanding of these patients’ dynamics. Basseches, for instance, notes that Mr. A’s competiveness, expressed masochistically as wanting to be the “best loser there is,” turns “oedipal competiveness upside down” (p. 265). But then she notes how he quickly regressed to expressions of a primitive primal scene fantasy that turns triumph into sexualized and exhibitionistic violence.
Each discussant brings to bear his or her unique take on the cases. Here are a few examples of the creative formulations and suggestions to be found throughout the volume: Robinson’s discussion of the use of projective identification, a concept employed in most of the formulations here, is especially illuminating. In the case of Diane, she demonstrates how the patient projects her inner pain into an internal object and then omnipotently repairs it. This dynamic underlies the patient’s consistent denial of reality. In the case of Mr. B, McBride too gives an excellent discussion of the multiple functions of projective identification. Grotstein offers the intriguing suggestion that Mr. A tries in his mind to destroy a hated transference object in order to know the real object, the analyst. Rockwell makes sense of Mariah’s fear of being smothered by her mother in terms of the patient’s not being able to differentiate the two of them. This dilemma is endlessly played out in a cycle of bulimia as she possesses and then rejects her internal maternal object. Rockwell also offers an interesting discussion, based on the somewhat unfamiliar work of Sodré and Sohn, of pathological identifications, which are more concrete and rely on more primitive defenses than “normal” identifications. Rangell discusses the importance of aggression in sadomasochistic patients by differentiating it from sadism and provides a concise review of Freud’s use of the terms. As an added bonus, in the context of this discussion of aggression he enlivens the perennial debate about nature versus nurture. Wurmser stresses the relationship of massive shame to sadomasochism. He is struck by the depersonalization that affects both Mariah and her analyst. Depersonalization and massive inner deadness serve as the patient’s defense against traumatic shame. Wurmser argues that masochistic fantasies, strong affects, and being the victim of soul murder or soul blindness (being unrecognized as an individual by one’s parents) are frequent sources of extreme shame.
In all these cases, countertransference dominates the clinical situation—for the analyst to endure, understand, and overcome. Paula Ellman had to withstand tremendous rage, doubts about adequacy, and feelings of being “ripped apart”; Goodman felt deadened and annihilated; Greenman felt small and powerless, invaded; Reichbart at first endured terrible boredom, before finding within himself the ability to stand stalwart against an onslaught of anxiety. I was impressed with all of these analysts’ honesty, capacity for self-awareness, courage, and endurance. The discussants elaborate on these countertransferential struggles and their place in the progression of the case. For example, Basseches demonstrates how the analyst shifted between an unconscious identification with the patient’s (abused) objects and the masochistic side of the patient, in the latter taking the role of protective parent. In this oscillation, she notes, there was a playing out of the patient’s experience of the primal scene.
In striking contrast to the usual reports of sadomasochistic cases, all these patients got better. Robinson’s comments on the case of Diane could be applied to all of these cases, as she notes the “psychic movement from severe sadomasochistic internal and external relationships toward space and capacity to endure the pain and recognition of psychic reality . . .” (p. 91). Thus, it is understandable that the discussants were inspired to address the question of therapeutic action in these specific cases and in general. Many stress that the therapeutic action comes from the analyst’s containing or tolerating the intense and often painful affects of these patients (especially through an understanding of the mechanism of projective identification). Some suggest that the containment itself is therapeutic; others that, in addition, the containment and toleration create trust in the patient that allows him or her to accept the analyst’s interpretations. Steven Ellman writes that in the long beginnings of such cases it is reflection/echoing, synthetic comments, and containment, rather than transference interpretation that is required and therapeutic. Similarly, the Novicks suggest that attention to positive aspects and/or possibilities of the patient’s adaptation helps the analyst realize the benefits of an open system of narcissistic regulation. Then, later in the treatment, the analyst can begin to interpret the central dynamics of the therapeutic interaction. For Hanly, one aspect of therapeutic action comes about through analysis of the patient’s destructive primal scene fantasies, which then leads to development of the patient’s capacity for linking and symbolization. The analyst is then able to help the patient know a whole world of split-off and repressed experiences, formerly repeated but not known. In sum, therapeutic action is achieved through bringing the patient’s split-off experience into the analytic setting, through self-analysis of the effects of the patient’s projective identifications, and putting into words the transference fantasies through the analysis of countertransference fantasies.
As I have said, the discussants offer many useful technical suggestions regarding the treatment of sadomasochistic patients. Bass, for instance, suggests that the clinical stance of not self-disclosing by the analyst can create an impasse, as the analyst unwittingly re-creates the patient’s experience of parents who would never admit their part—often sadistic or narcissistic—in the child’s problems. By contrast, Grotstein feels the analyst should not reveal his or her passions to the patient. Bass, like most of the discussants, stresses the importance of forbearing interpretation in the early stages of such treatments. He suggests that interpretation of aggression and envy early on would only intensify the patient’s intense shame.
This book is both engaging and helpful. It provides a rare look into psychoanalyses of sadomasochism that can overcome the negative therapeutic reactions, intractable stalemates in the transference/countertransference, and shared misery and hopelessness of analyst and patient so often observed in work with such individuals.