Monthly Archives: December 2016

Treatment of Masochism and self-punishment

How do we treat masochism and self-defeating disorder? My patient says: “I am strongly inclined to punish myself and think about this topic all the time. I’m always involved with a conscience. I always blame myself for everything.” How can ISTDP help her? Thanks to one of members for posting this question.

To start with, let’s go back to our handy concept: the triangle of conflict. Where do self-defeat, self-blame, and self-punishment belong on the triangle of conflict? Since they are all maladaptive behaviors, we can safely describe all of them as defenses. So the next question is this: what are the feelings the patient wards off through these defenses?

To find out, we conduct an inquiry into her problems.

Th: You mention that you punish yourself, blame yourself, and defeat yourself. Are these among the problems you would like me to help you with?

This first intervention establishes whether the patient regards these defenses as a problem [declaring an internal emotional problem] and whether it is the patient’s will to explore these problems [declaring will to engage in the therapeutic task].

The patient may say that it is a problem and then you can explore a specific example where she notices this self-punishment coming up. Then you can find out through inquiry what her triangle of conflict is in that example.

However, the patient may say that she does not regard her self-punishment as a problem. That means you have no right to explore that problem because she does not regard it as a problem. Simple reflection of the contradiction between what she does and says may mobilize her unconscious will to health.

Th: So although you punish yourself and blame yourself, leading to a pattern of self-defeat, this is not a problem for you. [Mirror what she says to deactivate the projection of her healthy wishes onto you. Do not become the cheerleader for her strivings. If you do, she will oppose you.]

In response, the patient may repeat herself. If so, simply mirror what she says back, letting her anxiety and feelings rise as she gradually differentiates herself from her defense of denial.

Or the patient may say her self-punishment is a problem but that it is not her will to explore it.

Pt: It’s not that big a deal. Let me tell you about the party I had last night. [Defense of self-dismissal and diversification. Inviting the therapist to ignore her and her inner life.]

Th: Although you punish and blame yourself, this is not a problem you want me to help you with. If we don’t help you with your self-punishment, what will be the result? [Point out her defense and ask her about the price she will pay if she ignores her problem]

Pt: I guess I won’t get better. [Rise in alliance]

Th: Exactly. So we could ignore your problem and let it get worse, or we could explore it and see if can help you overcome your problem. Which way do you want us to go? [Point out the anti-therapeutic task and the therapeutic task and their consequences. Then find out if it is the patient’s will to engage in the therapeutic task.]

You may be asking yourself, “Why do we have such a hard time getting an agreement on the therapeutic task?” The patient has already told us that she has a pattern of having a goal but using defenses which defeat her and her goal. Now her goal is to overcome her problems in therapy with you. Naturally, her defenses come up now to defeat her. That is not a problem. It is an act of tremendous collaboration. She is showing you right away how she defeats herself.

Pt: I don’t want to look at this right now.

Th: Could this be an example of the self-defeating mechanism you were talking about earlier? You have come here with the goal of overcoming your problems. But as soon as we join forces, you give up and stop looking. Then we are defeated before we have even really begun. Do you notice that too?

Pt: I hadn’t thought about that, but I see what you mean.

Th: You certainly don’t have to look at your problems if you don’t want to but what will happen here as a result?

Pt: I won’t get anywhere.

Th: Yes. Then this therapy would end in defeat like all your other efforts. [Price] Why would an intelligent person like you want to defeat yourself here before you have even given yourself a chance? Why do that to yourself? [Questions to mobilize her unconscious alliance, the part of her that wants to become well but is hidden now.]

Therapists often get frustrated when dealing with such self-defeating defenses in patients. But rather than view this as a sign of a misalliance, I would suggest that this a form of alliance: the patient is revealing her defenses in a very collaborative manner. The oncologist does not get angry when he sees cancerous lymph nodes. He is relieved. “Ah. Now I know where the cancer is. Now I know how to treat it.” You are an oncologist of the soul, identifying these defenses (tumors of the soul), helping the patient see the cancer of her life so she can let go of those defenses that are destroying her life and killing her chances to fulfill her potential.

Once the patient acknowledges that her self-blame is a problem and she wants to overcome it, then we can go to the next step.

Th: Could we look at a specific example where this self-blame comes up so we can see what is triggering it?

Pt: It comes up all the time. [Defense: generalization]

Th: I’m sure it does. [Block the defense.] But if we don’t have a specific example, we can’t get a clear picture of your problem. [Price of the defense] So could we look at a specific situation where this self-blame occurs?

Pt: Whenever my boss talks to me. [Defense of generalization]

Th: So could we take a look at a specific example where your boss talked to you and you responded with self-blame? [Maintaining the focus on a specific example.]

Take home point: recognize that maladaptive behaviors are usually defenses. To find out the triangle of conflict: 1) ask what the problem is the patient wants you to help her with; 2) find out if it is her will to look at that problem; 3) explore a specific example where her defenses come up so we can find out what the triangle of conflict is that causes her problems. Remember that each of these questions can trigger one of three responses: 1) the answer; 2) anxiety; or 3) defense. If she gives the answer, go to the next step. If her anxiety is too high, regulate it, and then ask your question again. If she uses a defense, help her see and turn against the defense, and then ask your question again. In this way you maintain a clear therapeutic focus and deal with her “detours” of anxiety and defense while always returning to a therapeutic focus.

Since she is self-defeating in her life, she will helpfully reveal those self-defeating patterns in therapy so that you can help her see them and their effect, so she can turn against them to discover what the feelings are those defenses have always warded off.


When do I ask for feelings toward me?

“When do you process anger toward the therapist? I understand that doing so can be very helpful and lead to breakthroughs, but I have also read that when patients are experiencing projective anger we should not process the anger but  deactivate the projection. Then some patients get angry with us because of misunderstandings. Should we process their anger then or should we clear up the misunderstanding. For example, if a patient says they are angry with me for interrupting their long, detailed story because they perceived that I was bored or annoyed would it be better to process those feelings of anger or clarify that I wasn’t bored, but rather trying to interrupt what I perceived as the defense of story telling. I guess if I had some rules of thumb about when it is effective to process anger in the T that would be very helpful.” Great question!

You are not alone. As you rightly point out, this is a complex topic that does not yield a single answer. Anger can arise for many reasons.

Anger arising as a result of exploration.

When you explore the patient’s feelings and help him see defenses, this will cause emotional intimacy to increase in the therapeutic relationship. This rise in intimacy will trigger mixed feelings toward the therapist. On the one hand, the patient is glad. On the other hand, the he feels angry. This anger, a transference feeling, arises organically as a result of the therapy process. We explore it.

Th: You seem to be having a reaction to what I’m saying. What feelings are coming up here toward me?

Anger resulting from a misunderstanding where you could lose a conscious alliance.

A patient says he is angry because he doesn’t think the therapy is working. When he does so, we see no sighing. If the patient really believes the therapy is not working, the anger is the result of a misalliance. “I want you to help me. I don’t think the way you work with me is helping.”

We don’t explore this anger because it would worsen the alliance. After all, he just said the way you are working is not working. Why do more of it? Instead, check in with the patient and see if the two you can get consensus on what is causing his problems and how the two of you should work together.

Pt: “I don’t think the way you work with me is helping.”

Th: “Thank you for letting me know that. Obviously, you came here because you want to feel better, overcome your depression, and improve your marriage. We share that goal in common. Let me know what I’m doing here that is not helping you so we can see how we can make sure we get on the same page.”

He doesn’t think the therapy is working and believes it. Take him seriously. Find out what he thinks is not working. Then make sure you have consensus on the problems and what causes them. Then make sure you get consensus on the task. If you don’t have those forms of consensus, you will get a misalliance and lose a patient.

Anger arising from projection, leading to loss of reality testing.

If a patient projects that you are judging him and he believes that projection, he will be angry at you, as if you are a judge. Don’t explore his anger at you as the judge because that will only strengthen his projection. Instead, restructure the projection and re-establish reality testing so he can differentiate you from his projection. Then he will have an alliance with you instead of a misalliance with his projection. Examples of this can be seen in my book and in other blogs.

Anger due to interrupting the patient’s train of thought. No sighing.

Pt: “I’m getting angry at you. You keep interrupting me. I don’t like this at all.”

Here the patient does not understand the process or therapeutic task and is at risk of leaving therapy. The lack of sighing tells us that there is no unconscious anxiety. Thus this is not unconscious rage based on earlier figures in his life. Instead, it is conscious anger toward a therapist she really believes is not listening to her.

Th: Thanks for letting me know. Let me just check in with you. It’s true. I have been interrupting you when you criticized yourself. [Validate her.] When you criticize yourself, is that making you depressed? [Help her see the price of the defense.]

Pt: Yes.

Th: Do I have your permission to interrupt any self-criticism that I think might be hurting you and making you depressed? [Show her why you intervene when you do: to interrupt harmful defenses, not her.]

Pt: Now that you put it that way yes. Thanks for asking permission. Now I understand.

Anger due to interrupting their train of thought.

The patient says he is angry because you interrupt his train of thought, but he sighs and is detached. Since he sighs, we can explore feeling. And since he  detaches, we can address his wall of detachment.

Pt: You keep interrupting me! [sighs]

Th: And you are having a reaction to that. What is the feeling here toward me?
Take home point: when anger arises in the session, assess what causes it: growing intimacy in the therapeutic alliance, misunderstanding, projection, or therapist error. Once you know the source, you can help the patient.