Moral masochism in substance use disorder : the perspectives of psychodynamic therapists

Abstract

The current study aimed at investigating the manner in which psychodynamic therapists conceptualise and treat moral masochism in patients who use substances. A qualitative methodology was adopted for which five psychodynamic psychotherapists informed by diverse psychodynamic theories and experienced in working with Substance Use Disorder (SUD) were recruited. Five in-depth, semi-structured interviews were conducted with participants and data was analysed using Reflexive Thematic Analysis (RTA). The study yielded several key findings, including the existence of common factors linking moral masochism and substance use-related behaviours, such as the presence of dependency, aggression and a sense of disconnection and emptiness. Themes elicited from the data also included possible motives underlying patients' behaviours, shedding light on how, according to therapists, patients deploy these as coping strategies, defence mechanisms, methods for achieving a temporary sense of control and as attempts to expiate guilt. Essential considerations for therapists treating this patient group were also highlighted, including the relevance of recognising the self-sustaining cycle powering morally masochistic and substance use-related behaviours. Particular transferential challenges faced when treating such patients were also considered. The importance of reflexive practice in order to help navigate specific emerging issues of transference and countertransference was also emphasised.