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At times, the demand to understand a patient and frame a response leads the therapist (or analyst) to deepen or expand her clinical theory beyond what she already knows. This issue focuses on that patient-driven expansion of clinical theory.
Margi Kaplinsky and Shulamit Geller initiated a joint effort to understand, “the persistent nature of suffering and its manifestations, which seem to elude healing and consolation” (p. 245). They explicate the therapeutic application of this sadomasochistic configuration by first reviewing the existing concepts of sadomasochism they consulted and applying their own construction to a series of clinical examples. Doing so, they describe the interacting internal and interpersonal worlds as the play of dialectical engagements between subjective psychodynamics of sadism and masochism enacted in chronic reversals of “one-up” and “one-down” positions. Conceptualizing in terms of a sadomasochistic configuration allowed them to frame responses to those patients for whom “the return of suffering is ensured” (p. 245).
Rafael Ornstein presents Mr. D, a child regularly exposed not only to overstimulating stories of his mother’s sexual abuse, but to ongoing social involvement with her abuser and her inattentive family. Mr. D responded through chronic and deceptively successful dissociation. When Mr. D, facing a life crisis, returned for treatment, Ornstein found that his usual clinical stance of relying on his “intuitions, guided by my affective resonance” (p. 258), left him baffled, rather than informed. Every forward-moving interchange was followed by an intellectualized reversal or affective shut down. The irony that Ornstein recognized was that his resonance with the psychological cohesion resulting from Mr. D’s well-practiced dissociation concealed the chaos in the experience that has been dissociated. With this recognition, Ornstein expanded the reach of his empathy to include the Mr. D’s dissociated states enabling patient and analyst to