Masochism is perhaps one of the most misunderstood clinical structures in psychoanalytic psychotherapy. It has been removed from the DSM for largely political reasons and has thus disappeared from the psychological lexicon.
It is a term that is conflated with victimhood, reactivity, or submission; however, its true meaning as a personality style is more complex. Contrary to popular belief, it is not about deriving pleasure from pain. Rather, masochism, as a psychic structure, speaks to a particular relationship to suffering in the context of relationship, and ultimately, it speaks of the impossibility of desire.
To consider masochism is to imagine a limited relational world—one in which the subject is organized around a chronic attempt to elicit an Other who is present, reliable, and real. It is a structure built on hope, but a hope entangled with despair; a hope that longs to be disconfirmed.
Understanding Masochism in Psychotherapy
In therapy, patients with a masochistic structure often present with an outward passivity or self-effacing compliance. This can be misread as submission, or worse, as a lack of conflict. But the truth is the opposite: the masochist is in a constant, silent war. Their submission is a strategy, not a surrender. It is a way of compelling the Other to see them, to care enough to object.
This is perhaps best understood through the lens of early developmental trauma—a landscape in which the child, faced with an unpredictable or unavailable caregiver, finds ways to bind that caregiver to them through their own diminishment. Pain becomes a means of tethering; the masochistic gesture is therefore a form of protest and
preservation.
Why Desire is Foreclosed in Masochism
Desire is relational. It arises in the space between self and Other. To desire is to risk separation, to accept lack, to move beyond the orbit of the parent and out into the world.
But for the masochistic patient, desire is foreclosed. To desire is to risk losing the tenuous connection they have built through suffering. To want something for oneself is to disrupt the fragile equilibrium that holds the Other in place.
Thus, desire is transformed into duty. The masochistic subject lives in a world where longing is transmuted into endurance. Pleasure becomes perilous and autonomy dangerous. They do not ask: “What do I want?”; but rather, “How can I continue to make myself indispensable through pain?”
Therapeutic Challenges in Working with Masochism
Working with masochism as a clinician can be excruciating. The patient often colludes in their own silencing, inviting the therapist into a bind where speaking feels like intrusion and silence like abandonment. They yearn for something new, but sabotage it before it arrives.
They compel the therapist to suffer with them, and then punish them for being affected.
Countertransference is a critical compass here. The therapist may feel drained, guilty, impotent, or enraged. These feelings are not obstacles to the work but rather the very territory in which the therapy takes place. Masochistic patients invite the therapist to feel what they cannot speak: the unrelenting burden of having to remain needed by never being whole.
How Psychotherapy Can Support Change
Change, if it comes, does not arrive in the form of insight or catharsis, as it never does with depth psychotherapy. It emerges slowly, through the painstaking work of tolerating ambivalence and separation. It begins when the patient can glimpse the possibility of being wanted without having to suffer to be seen. When the therapist can survive being hated and still remain. When desire is no longer experienced as a betrayal.
Masochism, then, is not about enjoying pain. It is about avoiding the terror of wanting. And therapy, at its best, becomes a space where the patient can begin to uncouple connection from suffering and recognize that to be desired is not to be destroyed.
Conclusion: Grieving the Loss of Desire
To sit with a masochistic patient is to sit with the unspoken contract of early trauma: I will suffer so you will stay. To work through it is to grieve not only what was done but what was never allowed to be desired. It is to open a crack in a closed system and let in the dangerous possibility that love need not be earned through pain.
Ultimately, the masochistic patient has to decide that rather than being punished, or becoming the punisher herself, she instead accepts that living well is the best means by which to take revenge on her internalized (m)other.
Mark Vahrmeyer is a UKCP-registered psychotherapist working in private practice in Hove and Lewes, East Sussex. He is trained in relational psychotherapy and uses an integrative approach of psychodynamic, attachment and body psychotherapy to facilitate change with clients.
Further reading by Mark Vahrmeyer
Dissociative Identity Disorder: A Rare Trauma Response, Not a Social Trend
Why staying in your chair is the key to being a good psychotherapist
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