Jane works hard to achieve high professional positions — and then always does something that undermines them. Linda is unable to extricate herself from a relationship with a physically abusive man. John, a pleasant professional with his own consulting business, is struggling financially because he’s compulsively nice to his clients — if they express any kind of need or dissatisfaction, he feels compelled to give away a great deal of his time for free.

People whose personalities are centred on experiences of self-inflicted pain are among the most difficult challenges we face as clinicians. They may respond well to treatment at first, only to unravel and become ill again. Freud called it a “negative therapeutic reaction.” There was something in their character that wouldn’t allow them to get better.

A compulsion to help

The inner world of such people is dominated by the psychodynamics of masochism, a term coined by sexologist Krafft-Ebing. It refers to experiences first described in the book Venus in Furs (1870) by Leopold von Sacher-Masoch, where the protagonist has a dream of a conversation with a white marble Venus who taunts him with his sexual desire for humiliation and enslavement. Indeed, the book contains many elements that have entered our current understanding of sexual masochism as it describes suffering to achieve sexual excitement. It later became apparent, however, that many people unconsciously pursue suffering for purposes other than sexual pleasure. The term “moral masochism” describes this inclination in individuals who may or may not have masochistic elements in their sexuality.

Some degree of masochism is common in most of us. It can be a part of normal sexuality, while self-sacrifice for other purposes — motherhood for example — can be adaptive. It’s when the self-sacrifice is compulsive and pervasive that we think of a masochistic personality. Take John, described above, for example: he was the oldest child with a younger sister who died after a long struggle with cancer. His devastated mother withdrew into a depression for many years. A heavy conscience became John’s constant companion and left him extremely vulnerable to the demands of people who felt wronged and/or entitled to special treatment. Although he was able to connect this self-defeating behaviour with his feelings of responsibility for his sister’s death, it took years before he gained some control over his guilt-driven compulsion to help.

The patient’s paradox

Moral masochists can be difficult to deal with in the office because they often complain loudly yet seem to reject help. Some have a deep streak of self-righteousness and spend a great deal of energy proving that those they feel are treating them unfairly are morally inferior. Your approach should be compassionate but clear. Don’t allow special exemptions or privileges. Acknowledge the suffering, but keep the focus on the patient’s own role in creating whatever the current jam might be.