Narcissism and Sadomasochistic Relationships

John Rosegrant
Institute for Psychoanalytic Training and Research
People with narcissistic vulnerabilities often relate to others sadomasochisticallyeither exerting power, or submitting to others, or bothin order to manage their vulnerabilities and protect themselves from feelings of abandonment. Sadomasochistic experience often involves concrete thinking and limited playfulness or ability to use metaphor. In therapy, these difculties are often actualized in the patient-therapist relationship so that usual verbal interpretations may be of limited value, and the therapist needs to work to maintain a mutually respectful relationship even as the patient tries to draw him/her into sadomasochistic interactions. Because these difculties have roots in early childhood and are repeatedly reinforced by later experience, long-term treatment that provides ongoing opportunities for new experience and understanding will be most helpful. These ideas are illustrated with two case examples. C 2012 Wiley Periodicals, Inc. J. Clin. Psychol: In Session 68:935942, 2012. Keywords: narcissism; sadomasochism; relationship; development

People with narcissistic vulnerabilities frequently relate to other people sadomasochistically: They experience relationships in terms of who has power, and they try to dominate others, or submit to others, or both. Therapists working with narcissistically vulnerable patients are likely to hear them describe interactions and fantasies about other people in these terms, and are also likely to directly experience their patients relating to them in this manner. Why is this so? Narcissistic vulnerabilities are vulnerabilities of the self, including problems with self-esteem regulation, problems with identity and self-denition, and problems with shifting between different self-statesdifferent sets of sensations, feelings, and ideas. All of these problems of the self are at the same time experienced as problems in relating to other people: If my self-esteem is pathologically high or low, then I think I am not only exceedingly good (or bad), but also better (or worse) than other people. If I am not sure who I am, then I am not sure how I compare to other people. If I have trouble shifting between different self-states, then I have trouble tting into different social contexts that call for different self-states. This intimate connection exists between self-experience and experience of the other because we all begin life in a state where self and other are relatively undifferentiated, and we only slowly develop our identities and our sense of who other people are by separating them out of this undifferentiated state (Freud, 1914; Mahler, Pine, & Bergman; 1975; Winnicott, 1953). Although even at birth we are psychologically separate from our mothers in that we have innate psychological capacities, many of these capacities (e.g., preference for the human face, babbling, social smiling) serve to link us to our caretakers (Beebe & Lachman, 2002; Stern, 1985). Although psychological development has important heritable components (think of temperament, and the basic template for language), all early psychological development takes place in an interactional matrix with caregivers (Mitchell, 1988). Psychologically, then, the self begins partially merged with the mother, and remains always in relationship to others. Problems with the self develop out of problems in this early interactional matrix and are always manifested in a persons relationships, both actual relationships and implicit and fantasized relationships. People with narcissistic vulnerabilities are always struggling with who they are in relation to other people. This entails struggles with attachment and love: Do we care about each other? Need each other? Will you abandon me? It also entails struggles with power: Am I stronger or weaker than you? Where love and power join, we have the potential for sadomasochism.

Please address correspondence to: John Rosegrant, 4031 E. Sunrise Dr., Suite 101, Tucson, AZ 85750. E-mail: rosegrantj@gmail.com
C 2012 Wiley Periodicals, Inc. JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 68(8), 935942 (2012) Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.21897

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These struggles with love and power can be handled easily enough when the child has good enough parents who are well enough attuned to the child. Problems arise to the extent that there are mismatches between the childs temperament and basic needs and those of her parents. These problems will be even greater when the parents, because of their own difculties, threaten the child (openly or in subtle ways) with abandonment or loss of love unless the child conforms to the parents needs. The child then has no choice but to become attached to the mother of pain. Incipient sadomasochistic orientation is then reinforced during subsequent developmental periods, partly from parental input and partly because the child will tend to assimilate new experiences into his or her expectation of sadomasochistic relating (Novick & Novick, 1996).

The Nature of Sadomasochism

The original clinical use of the terms sadism and masochism was to describe the sexual perversions of attaining sexual pleasure by hurting or being hurt. These terms have been usefully expanded to mean emotional sadism and masochism: experiencing emotional satisfaction or comfort due to exercising power over another or submitting to anothers power. All sexual sadists and masochists are also emotional sadists or masochists, but the converse is not true: emotional sadism and masochism are very frequently found without sexual perversion. Ironically, although their relationships are lled with so much pain, sadistic and masochistic people can be quite powerfully attached to each other. The prototype of such a relationship is a marriage where one spouse is emotionally abusive to another, but where they stay together for a long time and are very resistant to any changes suggested by marriage counselors. Although in some cases such marriages are maintained partly for socioeconomic reasonsas when a woman with no viable options to support herself remains with an abusive husbandthis explanation does not hold in the majority of cases, because such marriages are found at all socioeconomic levels, and the woman as well as the man may be the predominantly sadistic one. The reason that such relationships can be so powerful is because both the sadist and the masochist are trying to master strong abandonment fears. It is as though the sadist is saying, No matter how much I hurt you, you can never leave me, and the masochist is saying, I will let you hurt me as much as you want, to make sure you never leave me (Bach, 1985, 1994). But lets return to the term sadomasochism. In addition to sadomasochism being more convenient to say than sadism and masochism, there is a psychological reason for the combined term: every overtly sadistic person is covertly masochistic, and every overtly masochistic person is covertly sadistic. Furthermore, people who struggle in this area often shift back and forth in whether they experience themselves and/or express themselves sadistically or masochistically (Bach, 1985, 1994). A sadist is always identifying with his victim, because he is trying to lessen his own internal pain: You are the one who is suffering, not me. And a masochist is always identifying with his victimizer: I know how much pain hurts, I will free you by taking it all on me. Furthermore, sadistic or masochistic behavior may simultaneously express its opposite. For example, sadomasochism can manifest itself in marriages where the overtly sadistic spouse may experience his or her partners weakness and passivity as extremely annoying, in which case we see that what on the surface is masochistic weakness also has a sadistic effect. Conversely, the overtly masochistic spouse may experience his or her partners rages and bullying as weak and childish, in which case we see that what on the surface is sadistic power also has a masochistic effect. Relatively brief and mild versions of such interactions are commonplace even in marriages that are based on satisfying mutuality. In fact, as all humans have the capacity for sadomasochistic interactions, this type of relating can be found in all arenas of life. For many people, sadomasochism is only a minor or occasional part of life, but for individuals with pronounced narcissistic difculties, sadomasochism is often a dominant mode. One more aspect of sadomasochism is of great clinical importance: sadomasochistic phenomena strike us as perverse, even when they do not include overt sexual perversions, because they involve willingly hurting loved ones and/or allowing loved ones to hurt us. This overriding of mutual loving, or inability to experience mutual loving, results from the great intensity of

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abandonment fears. These fears are formed by distortions during early developmental phases that produce impairments in the ability to symbolize ones experience, to think metaphorically, to play, and to think through what is going on from multiple points of view. A mind that experiences in this way does not experience fantasies and feelings as fantasies and feelings, but as factual reality. A person with a rich ability to symbolize may respond to a spouses (or therapists) lack of empathy with hurt feelings and a fantasy of being abandoned, but then think of how context and the other persons temporary state of mind account for what happened; a person with much less ability to symbolize may react to the same lack of empathy as an intentional hurt and an actual threat of abandonment, which are not ameliorated by information about context and the other persons state of mind. Painful fantasies and interactions are felt as imperatively real.

Treatment
Several expectations about psychotherapy with patients who struggle with narcissistic vulnerabilities and sadomasochistic relationships follow from the qualities described above:

r r r

r r

Abandonment fears will be prominent. Abandonment will be experienced as not only potential loneliness but also a threat to continuity and stability of the self. There are likely to be limits in symbolizing ability that will result in words and interpretation having limited value in helping the patient feel better. The patient will experience people in their lives, including the therapist, as actually sadistic or masochistic, and will behave in ways that induce such responses. Change will require experiencing the therapist as maintaining an atmosphere of mutual respect. The transference relationship will be highly charged. In particular, therapists will nd themselves presented with situations where they can respond in a way that will be experienced as sadistic, or in a way that will be experienced as masochistic, with very little chance of being experienced as not engaging in a power relationship. By the same token, the therapeutic relationship provides the best opportunity to help the patient change. If the therapist can do a good enough job of maintaining concern for the patient, maintaining respect for him/herself, and maintaining therapeutic boundaries, the patient will be able to begin internalizing these attitudes. In turn, the patient will improve his or her ability to symbolize, and recognize feelings as feelings, not facts.

Case Illustrations
To illustrate these technical points, I will discuss two vignettes, the rst from a patient whose orientation was primarily sadistic, and the second from a patient whose orientation was primarily masochistic. I will intersperse these vignettes with bracketed commentary about what was going on.

Case 1 Presenting problem and client description. Carly (Rosegrant, 2005) was a divorced editor and essayist in her 40s. She entered treatment complaining of depression, generalized anxiety, and difculty asserting herself. She stated that she had been in several failed therapies. Case formulation. Carlys difculties centered around her low sel-esteem and feelings of powerlessness, and her sadistic way of relating to others to protect herself from experiencing these feelings. She also had great difculty thinking metaphorically or understanding that there could be multiple points of view about a given event. For example, if she experienced someone as treating her badly, she was certain that person had treated her badly, and she thought there was no possibility that her own mood or state of mind or past experiences could have contributed to how she experienced the other persons behavior, or that the other person might have intended anything other than to treat her badly.

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Course of treatment. From the beginning, treatment involved Carly closely monitoring my behavior for signs of countertransference (her word). She often praised me for how much more helpful, straightforward, and respectful of boundaries I was than her therapists in previous failed treatments. At moments when she observed countertransference, however, she would accuse me of it over and over and demand that I do something to restore the previous treatment equilibrium. (Here we see sadistic behavior, but we can also see that it was defending against an experience of me imposing my self over Carlys selfso her sadism was defending against narcissistic vulnerability.) What she experienced as countertransference were comments or silences on my part that she felt challenged her way of understanding an interaction. For example, one time after she spoke about confronting a colleague for his rude behavior, she became momentarily silent and then began berating me for also being silent when I must have known that she needed me to validate her behavior because it had occurred in the context of our discussing over several weeks her inhibition of anger and assertiveness. Maybe I thought her confrontation of the colleague had been crazy and inappropriate. In these situations, any attempts on my part to encourage her to explore her feelings and fantasies were met with contemptuous accusations that I was imposing my reality on hers, in a way that repeated what she had experienced in all important relationshipswith her boyfriend, her exhusband, her father, and especially her mother. (Here, we see that my attempts to use language and usual forms of interpretation were not only unhelpful but also experienced as another hurtful imposition of my self over Carly.) These impasses only began to resolve when I stated in some way that my behavior had come from something in me, and had not solely been determined by Carlyin her words, that it was not all her fault. In the example given, I stated that it was true that something in me had contributed to my not speaking in a way that would have been helpful. (Here, was a point where I felt that I had the choice of behaving sadistically, by not accepting Carlys point of view, or masochistically, by accepting her point of view and admitting error while being pressured to do so. I chose the masochistic response because it seemed that Carly was so convinced that I was exerting power over her that only by me leaning in the other direction could she feel that the power differential was being adjusted.) The rst times we had these types of interactions, Carly interrogated me as to what specically my countertransference had been, but was relieved by my saying that although I needed to think that through, I did not think it would be helpful for me to reveal it. (Carly seems to respond by feeling safer.) Carlys pinpointing of countertransference problems gradually lessened, and simultaneously she began to gradually talk about how much I meant to her. She felt blissful when she thought about me between sessions, and she especially felt blissful during sessions. If we were misattuned, she usually no longer demanded that I confess to countertransference, but she would talk about needing to drink alcohol or exercise to the point that she caused herself pain, instead of depending on me. (She was struggling here with attachment and abandonment issues.) On rare occasions, she did drink heavily or exercise until she vomited or strained a muscle. The drinking relaxed her from stresses, somewhat as my good inuence relaxed her, whereas the physical pain relieved her feeling hopelessly dependent on me. She began to muse about how nice it would be if I would sing to her from time to time. My singing would maintain contact with her, and would be the kind of thing that she never got from her befuddled mother. (This was a wish for me to demonstrate how much I would take care of her to prove that she need not fear abandonment.) One day Carly said that although she knew I couldnt sing to her, it gave her comfort to think that I wanted to sing to her. She then said that she needed me to say that I wanted to sing. When I asked about the importance of this, she said that it would make her feel special and vibrant. She did not want to explore more; my questions again were a way of me imposing my reality on her. (Once again, Carly was saying she needed action, not mere words.) Carly demanded with more and more urgency that I tell her I wanted to sing to her, saying that she knew I wanted to do so. She sometimes yelled about how important it was, sometimes wept silently. (Shifting between sadism and masochism to try to calm her narcissistic vulnerability and fear of abandonment by forcing me to sing.) She also demanded to know why I would not answer. Encouragement on my part to talk about what the singing might mean, why it had become so pressing now, and whether our impasse was a reliving of something, all resulted in her

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saying that she didnt know. I interpreted that she was recreating past experiences with depriving people, and that she was trying to induce in me the helpless, controlled feelings with which she struggled. Carly said these interpretations made sense but at the same time were irrelevant and pained her, nor did sympathetic comments about her suffering help. The one comment that seemed to engage Carly enough for her to reect upon was when I simply explained that I would not answer that question, that I wanted to help her and did not think such an answer would be helpful. She said that she disagreed with me and she might have to quit therapy, but she seemed less frantically anxious. We cycled through such interactions several times. Carly then said that she was no longer sure if I wanted to sing to her and described this uncertainty as quite painful. (Because the uncertainty means abandonment is possible.) If I wouldnt answer whether I wanted to sing, I had to at least explain which therapists I read to justify my approach. She had done enough reading in psychotherapy to know that self-disclosure is advocated by some people. Would I be willing to read and discuss with her articles that she suggested? (She was using intellectualization to disguise sadistic control.) By now it was clear that exploration in the moment would be unproductive, so I simply explained that I also thought this kind of engagement would be unhelpful. Again Carly yelled and wept. But after a briefer time she became quieter, and she said that as misguided as I was, she could see that I wanted to help.

Outcome and prognosis. Gradually, Carlys demands that I state that I wanted to sing to her, or that I discuss theory around this issue, dropped away. She never directly explored the meaning of her demands, or why they became so urgent when they did. (Carly did not gain understanding, but through our interactions in which I showed that I did not need to control her and would not let myself be controlled by her she was gradually able to become less sadomasochistic.) But Carly did become more able to exibly shift back and forth in her associations between current life events, feelings about me, and memories. She began to associate more deeply to dreams. She began to tolerate painful affects for longer periods of time. At the same time, I began to feel that I was no longer under such intense scrutiny, that I was not being held to impossible ideals of tact, timing, and attunement in my comments or silences, that failures on my part would not result in attacks on me or on Carly herself. These changes appeared to result from improved self-esteem and less need for defensive sadistic control of other people, together with an increased ability to recognize other points of view and understand that how she experienced something was not the only possible way to experience it. Prognosis was encouraging because these were changes in fundamental outlook that enabled Carly to form lasting friendships and become less depressed and anxious. Case 2
Now let us look at a therapy with a patient whose orientation was primarily masochistic (Rosegrant, 2010).

Presenting problem and client description. Sally was a middle-aged married woman with one child. She consulted me because she was insecure and losing sleep over her new profession. Case formulation. Sally also had low self-esteem and felt powerless but, unlike Carly, she expressed these narcissistic vulnerabilities in a mostly masochistic way, berating herself as worthless and desperately trying to nd someone to take care of her. This made it very difcult for her to feel secure in her job. Course of treatment. One of the gains of Sallys previous therapy was that she had been able to change to a career she liked, and since she obviously still had strong feelings for her rst therapist, I asked if she had consulted with her about her current difculties. Sally said emphatically that she had not and would not because she did not want to see a woman again who would remind her of her mother. She said that it would not do any good for me to

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recommend that she contact her rst therapist because she would not do so and would simply nd someone other than me to work with now. The early part of our work together was lled with Sallys despairing comments that she would fail at her new career. She was having terrible trouble sleeping, lying awake in bed for hours. She tried reading herself to sleep, watching TV, turning the lights on or off, drinking warm milk, but nothing seemed to help. She eventually told me that she sometimes self-medicated with Ambien, and then drank enormous amounts of caffeinated energy drinks to see her through the day, with no improvement in her overall sleep pattern. Sally was ashamed and self-critical, berating herself as wasting time and as being my stupidest, most worthless patient. (Narcissistic issues of low self-esteem manifested by masochistically trying to convince me she was worthless.) Sally gradually told me more about her rst therapy. Her therapist was homely but comfortable with this, which Sally found more impressive than if her therapist had been a beauty. The therapy had been very helpful to Sally in several ways: she came to feel generally stronger and better about herself, she felt much more able to understand her son and tolerate his disappointments, and she had been able to nd the courage to change careers. Sallys improvements had been linked to being better able to tolerate feelings of her own mother having been both rejecting and falsely reassuring (therapy had helped with abandonment fears), as she often told her rst therapist and me that her mother liked to say, I am your friend like nobody else, even as she did things that Sally felt were rejecting. A few months into the treatment, Sally told me with great shame that she had in fact contacted her rst therapist between ending that treatment and beginning with me. She had asked the previous therapist if they could meet over coffee or lunch, and the therapist had suggested that Sally meet with her in her ofce instead. Sally found this more than humiliating; she accused her therapist of having lied to her. (An example of narcissistic injuryfeelings of humiliation leading to the masochistic experience of having been victimized by a lie.) For an extended period in the middle of the rst therapy, Sally had been despairing to the point of being suicidal about the way her mother had rejected her and felt that it would be impossible to belong in the world. Her therapist had chosen to reassure her with a paraphrase of her mothers statement: I am a friend like no one else. Sally had found this enormously reassuring, and had pulled out of her depression, but felt she had to hide unsavory parts of herself from her therapist to preserve this special relationship. She also assumed that it meant she and her therapist had a friendship that transcended their professional relationship, so she had felt safe in asking for a coffee or lunch date. She took her therapists refusal to do this as a rejection identical to what she had gone through with her mother, and it made a lie of the entire treatment. We discussed this issue often over the next year, although this was hard for Sally to bear because she said it made her feel too bad, and there was nothing that could be done about it the entire previous treatment had been ruined. (I seemed to have a choice between causing Sally the narcissistic injury of making her feel badwhich she would experience as my sadismby trying to address this issue, or sparing her pain by colluding with her wish to avoid speaking about an important topic.) It sounded to me like what had happened was that Sallys need to be saved met her previous therapists need to save her, in a way that resulted in a reoccurrence of familiar dynamics (an enactment) that overwhelmed Sallys psychic realitythe therapist really was a friend/mother, not just someone who felt like a friend or mother. (We see here a problem with symbolization, in that the therapy shifted from a place to discover meaning to a place where one meaning needed to be rigidly held.) What created the most pain for Sally was not the loss of her therapist, but the loss of the ability to think of what had happened as anything other than the fact that her therapist should be her mother and had failed at that. (Here, we see that the problem was not so much with the content of Sallys experience as with Sallys level of symbolizationshe was unable to think of her need for the therapist to be her mother as something that might change, or of her therapist being helpful in some other way if she could not be a mother, or of what motivations both she and the therapist had that led them to try to do something impossible, since a therapist cant be a patients mother.) Sally herself did not think contact with the therapist felt very important in and of itself, so she was puzzled by why it mattered so much to her. She took her therapists behavior as proof

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that the therapist was exactly like her mother, and so being treated differently than her mother treated her was not possible; thus, her pain was just the way things were and always would be. (This concrete thinking maintained Sallys connection with her mother by making other people inevitably feel like her mother.) She kept coming back to the fact that the therapist had done something to her or that she had been stupid to think she was offered something, and it meant that everything was ruined (Either way, Sally was a victim). Like Carly, whom I described above, Sally could not recognize multiple points of view or see that her own wishes and fears were contributing to what had happened. Sally was trapped by this sense of the unbearable factuality of what had happened. Therefore, I understood the therapeutic task as trying to make Sallys experience freer, so that she would be able to know the external factual reality of what happened and experience how her own wishes and fears interacted with the external facts. Here is a brief vignette illustrating Sallys gradual change in this direction: Sally was speaking again about what her therapist had said to herI am a friend like no one else. There were two possibilities: either her therapist was a liarbut this could not be true, her therapist was too goodor Sally was a stupid dolt for believing her. Which did I think it was? (Sally was putting me in a bind because it was an impossible question to answer in her terms without me being critical [sadistic] to either the former therapist or to Sally.) As often happened when I listened to such material, I was of two minds: On the one hand, I understood the therapist as having made a severe, traumatizing blunder. (In this way of seeing things, I was identifying with Sallys narcissistic injury and seeing the therapist as victimizing her.) Her intervention had mixed up psychic reality with factual and co-constructed reality in a way that had devastated Sally. On the other hand, the therapists comment could be seen as innocuous, or as a creative way to help Sally out of a suicidal depression, and Sallys response could be seen as a powerful distortion based on her past experiences. (Here, I was identifying with the therapist in Sallys mind and seeing Sally as the problemI was identifying with Sallys masochism.) These thoughts, of course, were parallel to Sallys: Was her therapist a liar or was Sally a dolt? Both Sally and I were stuck in factual reality and having trouble nding psychic reality with its multiple meanings. I said to Sally that in her rage and pain she saw either herself or her rst therapist as being horrible. What we could say with certainty was only that something had gone terribly wrong in their communication. Sally said that she was a dolt for believing it, and I said that didnt take account of the fact that her therapist had said something that lent itself to being heard that way. Sally said, Why did she do this? Couldnt she know how it would make her feel? She couldnt get beyond thinking simply that her therapist was cruel. I said that indeed it was puzzling, because although we couldnt know for sure why her therapist had said it, based on everything Sally had told me it seemed most likely that her therapist wanted to help and hadnt understood how it would make Sally feel. Sally said she should have known. Sally then wondered what was wrong with her, why had she believed her therapist? I asked for her thoughts and she said she was stupid. I said that was like saying that her therapist was cruel: Sometimes she protected herself from her rage by criticizing her therapist and sometimes she protected her therapist from her rage by criticizing herself, but these were two sides of the same coin. Sally said she believed her therapist because she wanted to so much: She wanted her therapist to be a new mother for her. Could her therapist have wanted the same thing?

Outcome and prognosis. With these thoughts, Sally was beginning to step out of the concrete experience of being a victim by thinking about other possible motives in both herself and her therapist. As therapy progressed, we continued focusing on how Sallys wishes and fears interacted with her actual experiencesboth that actual mistreatment (trauma) caused her to feel worthless and needy, and that feeling this narcissistic pain led her to masochistically induce mistreatment or to experience as mistreatment actions that had been intended otherwise. This led to lasting improvement in Sallys self-esteem and greater ability to form mutually respectful relationships rather than interact sadomasochistically.

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Summary and Clinical Implications of the Two Cases

These cases show some of the various forms that sadomasochistic issues can have. Carly took primarily the sadistic role in relating to others, whereas Sally took primarily the masochistic role, although both had moments where they took the other role too. In the vignettes I have given, Carlys sadism was primarily focused on me, whereas Sallys masochism was primarily focused on her previous therapist and her mother. Carlys symbolizing ability was more impaired than Sallys, and as a result almost all of her change resulted from my being able to maintain an atmosphere of mutual respect during painful enactments, whereas traditional verbal understanding was more helpful with Sally. But the cases resemble each other in showing how self-esteem issues, abandonment fears, and sadomasochism are intertwined. Sadomasochistic feelings and experiences of the other served to maintain a connection to others in the face of abandonment fears, and to defend against closeness that would create the potential for recurrence of abandonment. In other words, sadomasochism defended against narcissistic injury by creating a type of relationship in which abandonment was experienced as less likely. These cases are typical in showing that sadomasochistic issues place great demands on the therapist. Patients are likely to try to unconsciously pull the therapist into their sadomasochistic world, and progress will only be possible, then, if the therapist is able to stay aware of his or her feelings on a moment-to-moment basis and maintain, as much as possible, perspective on the ensuing enactments. Because sadomasochistic difculties begin in early life and are typically reinforced subsequently by patients assimilating experiences into their sadomasochistic expectations, they become entrenched and are likely to be changed only by a therapy that perseveres over time and across transference/countertransference difculties.

Selected References and Recommended Readings

Bach, S. (1985). Narcissistic states and the therapeutic process. Northvale, NJ: Jason Aronson. Bach, S. (1994). The language of perversion and the language of love. Northvale, NJ: Jason Aronson. Beebe, B., & Lachmann, F. (2002). Infant research and adult treatment. Hillsdale, NJ: The Analytic Press. Freud, S. (1914). On narcissism: An introduction. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 14). London, UK: Hogarth Press. Mahler, M. S., Pine, F., & Bergman, A. (1975). The psychological birth of the human infant. New York, NY: Basic Books. Mitchell, S. A. (1988). Relational concepts in psychoanalysis. Cambridge, MA: Harvard University Press. Novick, J., & Novick, K. K. (1996). Fearful symmetry: the development and treatment of sadomasochism. Northvale, NJ: Jason Aronson. Rosegrant, J. (2005). The therapeutic effects of the free-associative state of consciousness. Psychoanalytic Quarterly, 74, 737766. Rosegrant, J. (2010). Three psychoanalytic realities. Psychoanalytic Psychology, 27, 492512. Stern, D. (1985). The interpersonal world of the infant. New York, NY: Basic Books. Winnicott, D. W. (1953). Transitional objects and transitional phenomenaa study of the rst not-me possession. International Journal of Psychoanalysis, 34, 8997.

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