The Masochistic Patient - A Case Study

Disclaimer

The Masochistic personality disorder was included in the DSM III-TR but removed from the DSM IV and from its text revision, the DSM IV-TR. This move was criticized by some scholars, notably Theodore Millon.

Notes of first therapy session with Sam, male, 46, diagnosed with Masochistic Personality Disorder

Sam is an advertising executive. He keeps sending letters with damaging and incriminating information about himself to various online, print, and electronic media. He knows that it is an extreme form of self-destructive and self-defeating behavior, but "it feels good afterwards, like I am cleansed." Does he enjoy it? He recoils: "Enjoy is a strong word." What things and pastimes does he find pleasurable? He likes classical music. When was the last time he has been to a concert? He can't remember.

Sam is gregarious and somewhat narcissistic. He likes being the center of attention. Still, he is a virtual hermit. He rarely exits his home and spends all his time in solitary activities. Why does he abstain from social contact? He tends to make a fool of himself: he often gets drunk and then loses control of what he says and does. "And that is not fun!" - he concludes sadly.

Sam is homosexual. He craves a stable and long-term relationship but keeps finding himself involved with unsuitable partners. These brief and stormy liaisons invariably end in heartbreak and financial ruin. Why didn't he seek help before? "I don't need help" - he sounds resentful - "I need advice." OK, then why didn't he seek advice before? He murmurs something inaudibly but refuses to share it with me. When I insist, Sam confesses that he has been to therapy a few years ago.

"She gave me all the wrong advice."- he complains and proceeds to list his former therapist's suggestions. I inform him that he is likely to receive very similar guidance from me and offer to assist him to assimilate these lessons, gain insights, and act of them. "That's more tha
I had bargained for when I came here." - he frowns - "Therapy is not exactly my idea of intimacy or companionships." I am not offering either, I tell him, merely support and some knowledge regarding the workings of the human mind.

But he is still on edge: "I understand that you practice brief therapy." Yes, that's true. "This means that we can see results in one or two sessions?" Sometimes. "Sounds more like brainwashing to me!" - he declares - "I don't like people tinkering with my mind like that." People always tinker with other people's minds. This is what fields like advertising and political campaigning and, yes, psychotherapy, are all about. "Cut you down to size." - he sneers - "Conform or die!"

Sam feels constantly manipulated by people who pretend to care about him. "Love" is a code word for subjugation on the one hand and obsequiousness on the other hand. Only weak people develop such dependence. He is shocked by the fact that I fully concur: "Love and dependence are mutually-exclusive."

At work, Sam is much loved and admired. He is known for his willingness to help others with their tasks. He dedicates time and attention and puts lots of efforts into these altruistic excursions while neglecting to attend to his own clients and thus jeopardising his standing in the firm and his career.

The only time Sam had a row with his superior was when he was promoted. "I didn't want the new job, though I admit that it far better suited my qualifications and experience." - he explains. He remembers the incident because that night he had a near-fatal accident. "Saved by the wheel" - he laughs disingenuously - "Someone else got the job while I languished at the hospital."

"What do you think of my story?" - asks Sam - "Am I not a pathetic piece of work?" When I ignore the bait, he proceeds to taunt and provoke me: "What's the matter, Doc? As a therapist, aren't you supposed to answer truthfully? Am I not the most screwed up, hopeless, miserable imitation of a person you ever came across in your practice?"