Shame: The Animator of Symptoms and a Challenge in Therapy

Guest Post by Susan Mahler

Susan Mahler, MS, MD, is a writer and psychiatrist who practices in North Adams, MA. Her work has appeared in STAT, The American Scholar, and other publications. She is working on a book about shame.

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“Guilt has been more accessible than shame to classical psychoanalytic treatment, since it more clearly reflects intrapsychic conflict between drive derivatives and internalized prohibitions, and motivates the patient toward confession, self-revelation, and the goal of forgiveness by the therapist. Shame, on the other hand, reflects feelings of defect, inadequacy, and failure of the self, and therefore leads to withdrawal and concealment in psychotherapy. As the desired antidote to guilt is forgiveness, the comparable yearning generated in shame is for acceptance by the self and by the analyst.” 

Andrew P. Morrison (1984). Working with shame in psychoanalytic treatment. Journal of the American Psychoanalytic Association.

“... analysis itself is a situation of almost ruthless self-exposure and intrusion into privacy. It is the art of self-revelation met by disciplined respect; yet shame is an unavoidable companion, inherent in this inevitably “shameless” procedure.” 

Leon Wurmser (1981). The Mask of Shame.

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I first met Claire in my second year of psychiatry residency, during my outpatient rotation. She was a dark-eyed, pale young woman, with several serious suicide attempts under her very slim belt. It took months for me to convince her to enter therapy with me; initially, she just wanted refills of her medications. She’d tried many; we tried some more. 

Claire came from a loving family, was very bright, and had attended boarding school. But at age 15, she developed severe anorexia and was forced to take a medical leave and return home. A hospitalization was arranged, but a bed was not yet available. Claire was a mess: skeletal, refusing to eat, and sneaking out to exercise. Her parents were anguished.

Finally, she was admitted. The next day, she learned her father had suffered a heart attack overnight and died. 

Years later, Claire remained severely depressed. She also maintained tight control over her eating and weight. The diagnoses listed in her chart were major depression and anorexia nervosa. It seemed to me, however, that these diagnoses failed to capture something vital about Claire. She was profoundly ashamed for having, in her mind, killed her father. But nothing I could say, no reassurance or reframing, along the lines of “You were a sick teenager—it was not your fault,” made any difference. Nor, for the first time, did any of my wonderful supervisors have any helpful advice. 

I worked as hard with Claire as I have ever worked with any patient. I cared deeply about her—and yet she got worse and worse, more and more symptomatic. She grew more isolated. I had become virtually her only contact. We had worked together for ten years when I took a job in another city. A year later, I learned that Claire had fatally overdosed.

That case stayed with me for years, as I tried to sort out what I might have done differently. The longer I worked with patients, the clearer it became that shame was an overlooked factor in psychiatric illness—yet, in all my years of medical and psychiatric training, I don’t recall encountering a single lecture or paper on the subject. I began to do my own research into this absent, malignant force.

Freud focused largely on guilt rather than shame, a bias that probably contributed to the subsequent neglect of this phenomenon. But it may well be that we clinicians avoid dealing with shame because it is so problematic. First of all, few people present with the complaint of shame, because shame by definition causes people to want to hide. In fact, the word “shame” is derived from the Old English and Germanic “skam,” or “skem,” meaning “to hide, veil or cover oneself.” (Wurmser, 1981) Second, as Claire’s case demonstrates, shame is devilishly difficult to treat. And, finally, shame takes innumerable forms—it is not a symptom itself but, in Nathanson’s words, a shaper of symptoms.”¹

Shame and guilt are often used interchangeably, but they are really entirely different animals. Guilt ensues when we do something or fail to act in a way that is considered morally acceptable. Shame arises when we find ourselves outside the scope of what is socially and morally sanctioned. Shame is therefore about the entirety of the self—the self is rejected and cast out. The experience is devastating, flooding, and associated with physiological arousal, like blushing and elevated heart rate. 

As illustrated in the example of Claire, shame occurs in the context of emotional investment. Profound shame implies that there has been a profound connection, or hope of such. The experience of shame is, in a sense, like falling from a height. 

According to Lewis, “Fascination with the other and sensitivity to the other’s treatment of the self renders the self more vulnerable to shame. Shame is actually close to the feeling of awe.”²

Most of us experience shame in our lives without lasting effects. For some, shame becomes a lens through which the ashamed person views the world, until the face of the shamer rotates arbitrarily, like the faces of children standing behind cardboard cutouts at county fairs.

Once you start looking for it and noticing it, shame is nearly ubiquitous in our patients. A few examples among many:

The teenager with undiagnosed dyslexia who was unable to read until the 6^th grade. She developed ways to distract and manipulate adults, eventually turning to bullying, theft, drugs, and alcohol.

The middle-aged man who always felt inferior, in the eyes of his parents, to his older brother. He manages his emotions at work, but his tendency to erupt in rage has driven away his family. 

The woman with bipolar disorder, graduate of an elite college. She spent all of her savings in manic sprees, and now lives on a fixed income. 

Research suggests that shame is very much linked to depression, as well as eating disorders, borderline personality disorder, PTSD, and substance abuse. Suicidality is also clearly linked to shame.

Interestingly, suicide, like shame, often follows a major loss or disappointment. It is the discrepancy between a prior state of existence or functioning and one’s current experience that seems to precipitate suicidal actions. Thus, chronic poverty is not a typical contributor to suicide, whereas a fall from economic prosperity is more frequently associated with suicide attempts.³ In one study, about one-third of suicides could be attributed to shame from failure in a major social role.⁴

The word “shame” itself is absent from the diagnostic criteria for depression in the DSM, but it is implied: one criterion reads “guilt, or feelings of worthlessness.” As we have learned, the feeling of worthlessness is associated with shame. 

Unfortunately, trainees learning about depression are generally taught a familiar mnemonic: SIGECAPS. The “G,” of course, stands for guilt. But studies have shown that it is shame, not guilt, that is linked to depression. 

In our efforts to be concise, we are obscuring the more important component of this criterion and leaving shame out of the conversation, with serious consequences.

Shame Corrupts Psychotherapy

Because shame presents in such diverse ways, and because the person who is ashamed has an acute tendency to perceive shame, the therapist can unwittingly assume the role of shamer.

Recall that shame depends on a respectful, emotionally invested relationship. I think most of us would define such a relationship as the groundwork for successful psychotherapy. This means that the same therapeutic elements which support treatment also create a potential breeding ground for shame.

Shame can leak into therapy in myriad ways. A therapist can miss or be late to an appointment. A psychiatrist can use language about medication that is perceived as shaming. There can be a disagreement about the bill. More subtly, a therapist may convey that they are frustrated with or fatigued by a patient. Did Claire perceive this? It’s possible—I was, in fact, fatigued. Often, small erosions of trust occur until a limit is reached and a crisis ensues.

Unlike guilt, there are few ways to deal with shame. Essentially, one can turn the hatred on oneself, or one can turn one’s rage outward. James Gilligan has eloquently demonstrated the relationship of shame to violent crime.⁵ It is also quite plausible that shame is implicated in many school shootings; the shooters are often alienated, bullied, and marginalized young men. To some extent, there is a gender difference in the tendency to turn shame outwards versus inwards.  

In the clinical setting, the emergence of shame can manifest as self-harm (turning on self), or shame-filled anger, a phenomenon described by Lewis as “humiliated rage.”⁶ Unfortunately, when we psychotherapists become the object of anger, we tend to respond defensively, often by invoking new diagnostic categories such as narcissism or borderline personality disorder. This, in turn, worsens the shame and perpetuates the cycle.

I have, after 25 years in practice, been anguished by many cases in which I have unwittingly perpetrated shame.

Several years ago, a young man came to see me because of severe depression and substance abuse. He showed a lot of reluctance and, in fact, irritability in our few sessions. The one thing on which he was clear was that he felt his mother never listened to him and would only talk about herself. My patient always kept his coat on, slouched down in his chair, offering little. I had the acute sense that he was waiting for me to make a mistake. And then, I did. I referred to an incident as having happened at his stepmother’s house rather than his mother’s. 

He abruptly got up, snarled, “This is not going to work!” and walked out the door. 

It was clear to me what had happened. In his mind, I had proved his point: that no one listened to him and that he was not worth listening to. Of course, he was more than ready to come to this conclusion.

This incident happened early in our work and, I suspect, was not devastating to this individual, although it might well have added to his distrust of psychotherapy. More damaging are incidents that occur after years of working together. The degree of shame is often proportional to the emotional investment. It seems likely to me that Claire felt responsible for driving me away, felt she had destroyed our relationship, just as she had destroyed her father. It’s hard to ignore the fact that my leaving may well have played a role in her suicide.

Clearly, there are no easy answers to dealing with shame in psychotherapy. I sometimes wonder if shame can be successfully treated in therapy, at all. Most of what I have learned, I have learned through making mistakes. Nevertheless, there are several things that I have come to find helpful:

1. Name shame when you detect it. Very often, I've had the experience of saying, “It sounds like you feel ashamed.” My patient often looks up and says, “I didn't think of it that way, but that feels right.”

2. Avoid repeated reassurances that patients don't need to feel ashamed. These are futile and, eventually, maddening.

3. Remind the patient that shame is a cage to which only the ashamed person has a key. This is a profound idea, though it is hard for people to accept.

4. Try to metabolize shame into guilt, a far more workable emotion. For instance, I might have said to Claire, “I can see why you would feel guilty about your father’s death, even though there was no way you could have prevented it.” This in particular was Lewis’ approach, and her understanding of the subject far surpassed mine.

5. Acknowledge when you've made a mistake, or even if you think you might have. When misunderstandings occur, acknowledge that the patient’s perspective has validity. 

Shame is an overlooked but integral component of psychological distress. Look for signs of it (i.e., the person whose gaze visits the floor, the patient who dwells on past successes, or castigates themself ruthlessly.) Name it; work with it. Learn from your mistakes.

Note: Patient histories have been altered to protect confidentiality.

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1. Nathanson, D. L. (1987). The shame/pride axis. In H. B. Lewis (Ed.), The role of shame in symptom formation (pp. 183–205).

2. Lewis, H. B. (1987). Shame and the narcissistic personality. In D. L. Nathanson (Ed.), The many faces of shame (pp. 93–132). The Guilford Press.

3. Baumeister, R. F. (1990). Suicide as escape from self. Psychological Review, 97(1), 90–113.

4. Breed, W. (1972). Five components of a basic suicide syndrome. Life-Threatening Behavior, 2(1), 3–18

5. Gilligan, J. (1997). Violence: Reflections on a National Epidemic.

6. Lewis, H. B. (1987). Shame and the narcissistic personality. In D. L. Nathanson (Ed.), The many faces of shame (pp. 93–132). The Guilford Press.