Monthly Archives: October 2013

How do you work with shame?

How do you work with shame?
Do you try to help the patient experience it as deeply as possible?

Shame has been understood from many different perspectives. Sylvan Tomkins proposed that shame is a sudden drop in positive affect. Freud and many other psychoanalysts proposed that shame results when we don’t live up to our ego ideal: who we would like to be. In that sense, it is a signal that we have departed from our ideals. For instance, we have all said of someone who did something wrong, “He should feel ashamed of himself.” In other words, shame can have a healthy function.

However, in psychotherapy shame usually shows up in pathological forms. A patient shares something then suddenly reports feeling ashamed. Some clinicians propose that shame is an inhibitory affect that inhibits the patient’s expression of other feelings. Gilbert and others such as Dean and Tangey suggest that it is essential to help the patient feel safe and not ashamed in psychotherapy.

How can we understand shame? I think of shame as having a defensive function. It certainly inhibits the patient from revealing her feelings. Now here is the interesting question: In front of whom does the patient feel shame? See, every defense has a transference dimension. What do I mean? Let’s suppose I’m talking to my wonderful colleague Tobias Nyquist in Stockholm. If you haven’t met him, he’s a terrific guy. If I am talking to Tobias, I have no reason to feel ashamed. Tobias is a kind, loving, accepting man who would never shame me in a million years. He’s kind of like you. Now, if I project an image of my shaming father onto Tobias, I will feel ashamed, as if Tobias is shaming me or will shame me. Briefly, if I am in relation to Tobias, I will feel fine. If I am in relation to the projection of my shaming father, I will feel ashamed of myself. Or….I might shame myself and say terrible things about myself so this shaming father won’t shame me.

In other words, I think of this as a character defense. Let me approach it another way to clarify this issue. If I were your patient and you asked me about my anger, I might project that you are judging me for my anger. In response, I might get depressed, anxious or depressed. I would be in relationship to a judging therapist. If I project that you would shame me, I would feel ashamed or I might shame myself before you could do it to me. In this sense, I view shame as the result of projection of the superego. I don’t view shame as a feeling that occurs in isolation. I view shame as a feeling that arises in response to projection of the superego onto the therapist.

That’s why one of the best things we can do is to help the patient differentiate you from the projection.

Pt: I feel a lot of shame right now telling you this.

Th: Is there any evidence here that I am shaming you?

Pt: No. But I feel that way.

Th: Of course! That’s why we need to check to see if I am shaming you because that would be terrible.

Pt: I don’t see any evidence yet that you are shaming me.

Th: So could that be coming from your mind?

Pt: Yes.

Th: So could there be a critical mechanism in your mind that is shaming you and putting you down?

When the patient can differentiate you from the projection, her shame vis a vis you will drop. Then you can restructure the character defense of self-shaming.

Th: Could this be a way you shame yourself?

Pt: But I feel ashamed.

Th: So you tell yourself that you should be ashamed to be a human being with human feelings. Could that be hurting you?

Pt: I know it hurts but I feel ashamed of myself.

Th: If I were your feeling I would be saying to you, “Why do you tell me, your anger, that I should be ashamed of myself? I’m just trying to protect you. I am a force of nature that was given to you to protect you from people who hurt you. Why do you tell me to be ashamed of myself when all I try to do is protect you? I love you. Why do you shame me?”

Another way to look at this is to understand that the patient shames herself as she was shamed in the past (character defense). When we help her see how she enacts this relationship, she can more easily see the cruelty and irrationality of this defense. Further, when she no longer identifies with the shaming parent, she can then face her rage toward the shaming parent.

Do I ever explore and deepen the patient’s sense of shame? Why would I ever want to help a patient feel even more deeply ashamed of herself? Shame cripples the patient. Shame prevents the patient from exploring her potentials. When teaching someone to drive we wouldn’t encourage her to keep her foot on the brake. We don’t explore feelings that cripple and paralyze the patient. We help the patient recognize those feelings as the bars of her prison. Instead, we help the patient explore the feelings hidden by her shame.

Th: Can we find out who you really are underneath the shame?

Th: Can we take a look and find out what the feeling is underneath that the shame is covering?

Shame is the grimy garment that hides the person underneath. If we explore the patient’s shame she only feels more ashamed of herself. That’s the last thing she needs. Instead, we need to explore the feelings underneath her shame. The feelings that will liberate and mobilize her to fulfill her potential. Shame is just the darkness which hides the light of her being which she could reveal.

Is it anger or is it just blaming?

“When should I explore anger versus restructure externalization? Are these just two poles of a continuum (narrative truth versus historical truth)? I often find myself seeing it neither as black or white but grey. But then, how do I know I’m really exploring a feeling versus reinforcing the patient’s defense of blaming others?

For example, one patient is continuously angry towards her mother for past and present misdeeds. But many times the patient seems to be blaming her mother for her problems or she projects onto her mother, so the mother looks two-dimensional.

When the patient feels her anger, it seems limitless and does not lead to grief or guilt. How can I assess whether I should explore her anger or restructure her defense of externalization? If the mother is being portrayed as more of a part rather than whole object, what do I do?” Thanks for this great and essential question of psychodiagnosis: is it feeling or defense?

When patients feel angry over a wrong done to them in reality, we explore their anger. As we do so, anxiety will rise in the body, and defenses will come up to repress the anger. We will explore the anger, regulate anxiety if necessary, and help the patient see and let go of defenses that prevent the full experience of the anger.

When patients feel anger that is the result of externalization, the anger is not the underlying feeling; it is a defensive affect, the result of the defense. For instance, let’s suppose the patient above reports on some terrible things her mother did to her in the past. As the therapist explores the patient’s anger, her anxiety rises, then she reports on ways she hurts her self. Perhaps she sabotaged herself on the job. Perhaps she screamed at her boyfriend who then left her. So we see that when she feels rage toward her mother, she turns it back onto herself. THEN she does one more thing: she externalizes. “My mother has damaged my life.” Rather than see how her defenses hurt her, she blames her mother. She views her mother, not her defenses, as the cause of her current suffering. Then she rages at her mother, the supposed “cause” of her suffering.

If we explore her rage toward the mother as the supposed “cause” of her difficulties, her rage will be limitless. Why? Because her rage is toward a projection. As long as her projection continues, her rage toward the projection will continue. Thus, when you run into “limitless” rage you are always dealing with a defense of some kind. Sometimes limitless rage is a defense against facing complex feelings. Here, limitless rage is a defense against facing the ways she hurts and tortures herself.

Now, as our questioner asked, how do we know if this rage is the feeling or a defensive affect (the result of a defense)?

Anxiety: feeling triggers anxiety and defensive affect does not because it functions already as a defense.

Defense: feeling triggers a defense and defensive affect does not because it already functions as a defense.

Feeling architecture: has the shape of a wave, rising and then falling after its expression; defensive affect is flat and steady, fluctuating only with the fluctuations of the projection upon which it is based.

Trigger: feeling is triggered by a stimulus in reality, defensive affect is triggered by a stimulus in fantasy such as a projection.

Narrative versus historical truth is another issue. Obviously, the rage that arises is often based on a childhood memory of an early event. As children, when frustrated, we may look at our parents through the spectacles of our rage. And that is what we will remember. Even though this is a “narrative” truth, we can use it in therapy to access the complex underlying emotions to get to the emotional truth.

When the patient is angry with her mother over something wrong done to her, we can explore the anger. However, if the patient hurts herself then blames mother for the ways she damages her own life, then this narrative has a defensive function. “If I can blame my mother with this narrative, I don’t have to face how I have hurt myself.” Thus, we must help the patient see how she, not her mother, is damaging her life today. Once that externalization is undone, we can examine the patient’s rage for what mother really did rather than have the patient retell her limitless rage for what mother didn’t do (but what the patient did to herself: damage her life today).

Take home points: notice if the patient’s anger triggers anxiety and defenses against its expression. If so, this is a feeling. If not, her anger is a defensive affect. If she blames others for her suffering, start looking for ways the patient hurts herself. Once she can let go of her externalization, she will no longer rage at mother for destroying her life (the imaginary stimulus). Then she can face her rage toward her mother for what mother actually did (the stimulus in reality).