Understanding « Negative payoff »

The term « negative payoff » first started in use amongst the psychoanalytical community in the 19th century. It is the idea that each symptom, each illness, actually protects us from what is perceived by the body to be an even greater danger.

So for example: a woman who repeatedly has severe and violent migraines, which seem to appear late in the evening, and mostly on weekends or her days off work. Upon a little digging in therapy, it becomes clear that these migraines, however painful, give her an excuse not to have to engage in intimacy with her husband. After prolonged therapy this young woman finally summons the courage to file for a divorce, and the migraines disappear.

Another example: a young woman has debilitating endometriosis, giving her painful and long periods, making her tired and anemic. But this is not really what bothers her; what she suffers from the most, as she says in our first session, is her incapacity to get pregnant. Her husband really wants children, so do the grandparents, and it is very difficult for the young woman to come to the realisation, in therapy, that she is actually very ambivalent about being a mother. If she ever did get pregnant and have to take care of a child, it would jeopardise her dream career of being a writer and travelling intensively. Yet she is unable to assert herself and say NO, so her body does it for her. Her endometriosis, however much it makes her suffer, is actually a defense mechanism that protects her from an even greater evil; or what her subconscious perceives to be an even greater evil: motherhood.

In this above example, two issues are possible. First we would gave to assume that the young woman has the courage to persevere with her therapy sessions and find out her true desire, or what she really wants, not what her surroundings want. in the « happy end » version, she would assert herself vis-à-vis her husband, her parents and societal expectations, start using contraception, and her endometriosis would fade away, no longer serving its purpose.

In the not so « happy end » scenario, even though she could admit to herself that motherhood maybe wasn’t for her, her endometriosis would continue, becoming more and more severe. Why? simply because of guilt. In this example, the « negative payoff » of an illness is simply to punish us, in a very primal masochistic way. In this example, the young woman doesn’t want or is afraid of motherhood, but she feels extreme guilt. She feels that a woman who doesn’t want to become a mother is simply a bad person. And bad people must be punished. So, sadly, the endometriosis is her way of punishing herself.