The author defines "auto-erotic asphyxia" as "a paraphilia or sexual perversion, with a compulsive desire for a state of oxygen deficiency and/or strangulation to enhance sexual-erotic arousal and orgasm in a solitary auto-erotic activity." In the literature there is little about live practitioners who, it is believed, die sooner or later due to loss of control when organized safety mechanisms fail. Mr X sought help because he was afraid that he might die from his compulsive practice. Mr X remembers having to be quiet and tidy as a child; he felt continuously isolated and lonely. At approximately 4 years of age, Mr X began fantasizing imaginary friends and games in which he would organize triumphant endings with himself always the victor. In individuals like Mr X, who have experienced, consciously or unconsciously, early cumulative trauma, with rejection and humiliation, overwhelming anxieties threaten the ego's capacity to contain the conflict. Through the interplay of sexual desire, hostility, and the eroticizing of anxiety, temporary relief is experienced from the internal conflict that threatens engulfment of ego functioning. This case study of Mr X's treatment selects some clinical material from the art therapy sessions that span 8 months. The art became a means for Mr X to objectify his feelings and a context for discussing his feelings with the therapist. Currently, Mr X practices auto-erotic asphyxiation less compulsively, with weeks in which he says "it is quiet," meaning nonexistent. His masturbatory activity remains attached to the same homoerotic sado-masochistic fantasy, which he says is less intense. During the last year, he has begun to integrate his experiences of gratification and disillusionment through an enriched social life.