Battling the Life and Death Forces of Sadomasochism; Clinical Perspectives.

Banbury, Samantha Anne ; Charlton, Megan

Battling the Life and Death Forces of Sadomasochism; Clinical Perspectives

Harriet I. Basseches, Paula L. Ellman, and Nancy R. Goodman

CIPS series on the boundaries of psychoanalysis, KARNAC Books Ltd, London, 2013, 294 pages. Paper Back. [pound sterling]26.99 (paperback)

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This book presents a beautifully descriptive psychoanalytic account of the clinical boundaries and the life and death forces involved in sadomasochism. The text eloquently examines four patient cases providing detailed insight into the unconscious collision between transference and countertransference forces. Transference refers to unconscious feelings being directed from the patient to the therapist. Conversely, counter-transference refers to the re-directed unconscious feelings from the therapist to the patient (Etchegoyen, 2005; Freud, 1960; Kapelovitz, 1987). The authors are psychoanalysts from varying schools of thought and collaboratively provide an illustrative and intuitive means of guiding such driving forces involved in the therapeutic arena. The authors refer to psychic sadomasochism, a term used to describe sadomasochistic relationship images in the psyche which are enacted onto others, including the analyst, within the therapeutic arena. The authors stress that: "Most of these patients do not overtly enact sexual sadomasochistic scenes" (Basseches, Ellman & Goodman, 2013, p. 5). Therefore, this does not refer to the consensual giving and/or receiving of sexual pleasure in the context of enacting out pain and/or erotic humiliation. The understanding of how the psychic sadomasochistic communication unfolds during the analytic process has been acquired via the authors' extensive clinical experience as presented in the clinical case studies.

This book is part of the CIPS Book Series on the Boundaries of Psychoanalysis. The book aims to expand the reader's understanding of psychic sadomasochism by using varying theoretical perspectives following each of the case examples; indeed, each of the presenting four cases is followed by three case discussions. This is both an intriguing and captivating means of drawing the reader into the fascinating world of human pathology. Such patient descriptions prompt an array of emotions and possibly even that of relatedness amongst readers. For example: "The analysis seems impossible. In our study group we came to identify as sadomasochism the hold these patients were having on us and our analysing capacities. Each of us felt tempted by despair. Were we incompetent, or were our patients unanalysable?" (Basseches et al., 2013, p. 3).

The book is clearly outlined and well structured. It commences with an introduction to psychic sadomasochism in the clinical realm and the intersecting forces and development of psychic sadomasochism. This is followed by descriptions of the case studies and subsequent discussion of each one. All presenting cases are very well detailed and provide a means of applying the conceptual aspects of psychic sadomasochism into an understandable clinical context. Further the presenting cases include a component of the transcript embellishing the case descriptions. Whilst a heavy read, these descriptions are essential; indeed, their absence would have resulted in the provision of a superficial overview. Despite varied contributions being made, it is evident that the descriptions provided have an element of unity, and hence overlapping congruent themes depicting the therapeutic psychic sadomasochistic forces involved. The descriptions are captivating and encourage the reader to further explore the sometimes subconscious torment of the patient, analyst and even the reader. Arguably, the intertwined psychic sadomasochistic elements involved in transference and counter-transference reaches beyond the written text and highlights the vulnerabilities of the therapist. Each chapter has a wide range of references and are cited very clearly.

In chapter 3, which is entitled, "Sadomasochism in work and play with Diane" (p.29), Dr. Paula Ellman provides the fascinating case of Diane, where masochistic elements had been presented in the context of passive helplessness. This case included issues of sexuality, disability, relationship concerns and a powerfully motivated work-oriented modus operandi. The analyst recounts feelings of failing her patient, "having nothing to offer her" (Ellman, 2013, p. 29) combined with anger at the patient for her apparent lack of appreciation. The discussion of the case has been explored by Alan Bass, Jack Novick and Kerry Kelly Novick, and Marianne Robinson. The authors provided an insightful and fascinating means of evaluating this case. Whilst these discussions varied, conceptual reference to the beating fantasy, a term used to exemplify the closeness between pleasure and suffering, was made. Therefore, a clear depiction of how transference and counter-transference became enacted within the therapeutic arena was insightfully presented.

In chapter 7, which is entitled, "Sailing with Mr. B through waters of hurting love" (p. 95), Dr. Nancy Goodman provides a descriptive and honest account of her thoughts regarding Mr B. The case centred on issues of annihilation, or total destruction and castration, the fear of which manifested in the context of psychic sadomasochistic forces. The author states: "The repetition compulsion was alive in regard to constant replaying of someone attacking the other resulting in a sense of psychic death or a state of overwhelming stimulation" (Goodman, 2013, p. 95). The discussion of the case was via the riveting observations of James Grotstein, Margaret Ann Hanley and Terrence McBride. The authors explored the notions of hurting love, annihilation anxiety and the use of sadomasochistic relationships to perpetuate anxiety avoidance. An illuminating and enlightening overview of how transference and countertransference oscillated between sadism and masochism and, therefore, helplessness and revenge had been presented.

In chapter 11 entitled, "Eating for emptiness, eating to kill: Sadomasochism in a woman with bulimia" (p. 157), Dr. Andrea Greenman presents an interesting account of the case of Mariah who had entered into treatment mid-life owing to her bulimia. Bulimia is an eating disorder characterised by binge eating followed by efforts to prevent weight gain (Hay & Claudino, 2010). The case centred on issues of childhood abuse where a clear depiction of sadistic counter-transference and transference between the analyst and patient became evident. Feelings of aggression, avoidance and narcissism were concisely captured within the text. The discussion of the case was via the descriptive accounts of Steven Ellman, Shelley Rockwell and Leon Wurmser. The sadomasochistic manifestation within transference and counter-transference presented as a fascinating subconscious battle of wills between analyst and patient. The lateness of the patient observed with additional avoidance behaviours, in the context of shame, became the perceived fear of penetration. This was an intriguing case and certainly one that touches the reader's relatedness to similar cases.

In chapter 15, which is entitled, "The primitive superego of Mr. A: Sadistic revenge fantasies, arousal and the masochistic remorse" (p.229), Dr. Richard Reichbart provides an honest account of his patient, Mr. A, describing him as tedious, repetitive and anxiety provoking, "frequently threatening suicide at the end of the sessions" (Reichbart, 2013, p. 229). Here, the sadomasochistic fantasies became more evident as the therapeutic alliance developed. This was a particularly complex and fascinating case which detailed how Mr. A withheld information via an unconsciously sadistically aggressive mind set. Such processes involved were "almost all sexual in nature" (Reichbart, 2013, p. 231). Sheldon Bach, Harriet Basseches and Leo Rangell then provided thought-provoking discussions of this case. Whether the focus centred on narcissism or a faulty Oedipal developmental issue, where the repressed emotional desires had transgressed into the fear of homosexuality, the authors captured the patient's sadomasochistic unconscious fantasies and the different representations of therapeutic countertransference.

The authors acknowledge the life and death conflict in object relations theory by detailing the meaning behind the life and death struggle central to psychoanalytic transference and counter-transference. Interestingly, the authors explain how "as psychoanalysis deepens, the battle of the life and death forces intensifies and repetition compulsions take hold" (Basseches et al., 2013, p. 6). According to the authors, this repetition may lead to patient withdrawal and, thus, is critical in understanding ways to improve the analytical process. Indeed, having a heightened understanding of these transference and counter-transference forces can ultimately strengthen the therapeutic alliance. Therefore, "realising the vital role of the pleasurable addictive quality of sadomasochism helps to facilitate a transformational symbolising process" (Basseches et al., 2013, p. 13).

It is potentially an outdated concept to assume that the application of contemporary psychoanalytic principles is solely to benefit the psychoanalyst. The authors stress that "readers will be better able to acknowledge sadomasochism in their patients, in themselves and in the material and enactments taking place in their treatments" (Basseches et al., 2013, p. 7). However, this book goes beyond that and by "capitalizing on our diversity of thought by creating opportunities for probing clinical dialogue across societies and schools of thought" (Perlman, 2013, p. xix), it targets a wider audience of health care professionals and academics in varying disciplines. In conclusion, this is a thought-provoking and captivating book. It is an essential read for academics and clinicians working in the areas of psychoanalysis, counselling, psychiatry and psychology. Finally, one hopes this book will encourage a better understanding of psychic sadomasochism and "...facilitate a transformational symbolising process" (Basseches et al., 2013, p. 13) thus strengthening the therapeutic alliance between analyst and patient.

Reviewed by Samantha Anne Banbury. Cpsychol, PhD, Cert Couns and Megan Charlton MSc and Cert Couns

References

Hay P.J., & Claudino, A.M. (2010, July 19). Bulimia nervosa. Clinical Evidence, pii: 1009.

Kapelovitz, L.H. (1987). To love and to work: A demonstration and discussion of psychotherapy. Lanham, Maryland: Jason Aronson.

Freud, S. (1960). The ego and the id. New York: W.W. Norton.

Etchegoyen, H. (2005). The fundamentals of psychoanalytic technique. Karnac Books: London.