An investigation of the psychodynamic conceptualisation and treatment of moral masochism in substance use disorder

Abstract

The current study aimed at investigating the manner in which psychodynamic therapists conceptualise and treat moral masochism in patients suffering from substance use. Therapists’ perceptions of the possible role moral masochism play in the cause and perpetuation of substance use and its implications for treatment were explored. Psychodynamic therapists’ diverse ways of conceptualising moral masochism were compared and contrasted, and the manner in which they deal with the particular transferential challenges faced when treating such patients was investigated. A qualitative methodology was adopted, in which five in-depth, semi-structured interviews with psychodynamic psychotherapists, whose work is informed by diverse psychodynamic theories and who have experience working with Substance Use Disorder, were conducted. Data was analysed by means of Reflexive Thematic Analysis (RTA), in accordance with the guidelines provided by Braun and Clarke (2006, 2016, 2021). The study yielded several key findings, including the existence of common factors linking moral masochism and substance use-related behaviours. Some of these common factors include dependency and feelings of inadequacy, the presence of aggression towards the self and others and the presence of a sense of disconnection and emptiness. Possible motives underlying the behaviours of patients suffering from moral masochism and engaging in substance use were also elicited as themes from the data, which shed light on how patients use such behaviours as coping strategies, defence mechanisms and as ways of achieving a temporary sense of control. Results also elucidate patients’ need to expiate guilt, including religious guilt, which participants believed contributes to this behaviour. Essential considerations for therapists treating this patient group were also highlighted, including the relevance of recognising the self-sustaining cyclical nature of morally masochistic and substance use-related behaviours within patients. The key role of considering patients’ full biopsychosocial context and how this may be feeding into their behaviours was also highlighted. Implications for treatment of this patient group included helping patients to develop ego strength and an internal locus of control, addressing guilt and helping patients relationally reconnect to themselves and others by encouraging personal growth and helping them to find meaning in their lives. The importance of reflexive practice in order to help navigate specific issues of transference and countertransference was also emphasised.