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.

 


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