Masochism Revisited: Nancy McWilliams on Self-Defeating Patterns

Nancy McWilliams’ body of work has made her one of the greatest assets to the psychoanalytic community. This past April Derner students, faculty, and alumni had the opportunity to hear her speak and engage in a Q&A session.

Nancy McWilliams, Ph.D., began her talk by stating that as a mental health community we have lost a sense of how powerful it is to understand the personalities of our patients: “Current psychotherapists are frustrated that this knowledge has not been acknowledged from other veins of the medical community.” She made it clear that her mission is to promote appreciation for personality factors in mental health treatment.

McWilliams reminded us about a shift in psychotherapy: “There was a time when psychotherapists saw themselves as healers, when being a psychotherapist was seen as a healing relationship, and now we are being put under pressure to become technicians, which is wreaking havoc on our self-esteem and identity.” She also remarked, “I do not know  any therapists that argue that therapy should not be based on research; however, being based on research is different from being like research, and therapists are under pressure to have therapy be like research.” She urged that personality and relationship issues should be emphasized in psychotherapy.

McWilliams continued by stating that personality ought to be understood dimensionally and said conceptualizing personality by traits does not capture the entirety of the patient. She called for attunement to internalized object relations, or relational patterns, and described the variations in personality organizations, such as the difference between a schizoid person and narcissistic person, to be based on “separate preoccupations.”

Regarding the requirement of a diagnosis  in  order  for treatment to be covered by insurance, McWilliams spoke about how we are “with the best of intentions… pathologizing normal life functions” of grief and sadness. She reminded the audience of an arbitrary decision in 1980 to eliminate depressive and self-defeating personality disorders from the DSM for the purposes of research. Additionally, feminists fought to remove self-defeating personality disorder, as they believed it would be misinterpreted to imply victims wanted to be abused. However, the Psychodynamic Diagnostic Manual (PDM) includes depressive and self-defeating personality.

McWilliams  highlighted the overlap of  depressive and masochistic cognitions and said that, in both, “attachment is predicated on suffering.” Masochistic and depressive defenses include: introjection, turning against the self, idealization of others, and identification with the aggressor.

When working with a masochistic patient, McWilliams advised reducing idealization by helping the patient verbalize their identification with the aggressor so that they can talk about their self-attacks, which then helps them to soften their self-criticism as they grow in insight and internalize the empathic function of the therapist.

McWilliams concluded by sharing a video of her working with a self-defeating, depressive patient characterized by relational and moral masochism. The video gave budding doctoral students and veteran clinicians alike the opportunity to observe many of the themes she had previously discussed. After the video, McWilliams made time for questions and discussion.