I view shame as a learned response, in other words, conditioned. And conditioned responses can be extinguished, directly or indirectly. A client who had been working on a number of fears suddenly sat up in her chair one day and exclaimed “I just realised my shame isn’t mine. I’ve been carrying my mother’s shame all these years”. This wasn’t the theme of our work, but it was the result of it - new cognitions arising of their own volition when we no longer see the world through a particular set of conditioned responses. So I think that shame can be successfully resolved, but most likely not via psychoanalysis.
Perceptive post - thank you! I, too, am surprised by the lack of attention in the literature to shame, especially around assessment of suicide risk. Joiner's ideas about burdensomeness in suicide victims comes close, but we don't teach trainees to listen for or see shame in individuals at risk. In fact, one might wonder if our emphasis on teaching objective measures of suicide risk, as useful as they are, also serve to distance ourselves from, displace and neutralize our shame around the possibility of losing a patient to suicide.
I have found the article "The Genesis of Shame" by J. David Velleman to be insightful. It is by a philosopher, not a psychologist, but I wish it were more widely known in mental health circles.
He argues that shame is essentially just the emotional pain we feel specifically from losing control of our social self-presentation, for any reason.
This could be due to a public failure or embarrassment. But it could also happen when we accidentally reveal something neutral or positive, but that we wished to keep private. It could be due to our bodies and faces physically betraying our emotions. And it could also happen when someone else influences how other people see you socially (for example, someone who experiences racist abuse in public may feel shame even if they reject the abuse and have no respect for the racist. conversely, someone might also feel shame if they are involuntarily made the center of positive attention.)
The way to stop feeling ashamed is to regain control of social self-presentation somehow, and there are many strategies to do this. You can try to integrate/publicly accept the shameful thing (if the shame is from an actual moral failure, then this would look like going from shame -> guilt). Or you can try to ignore the shameful situation and restore your control quickly, and surprisingly people will usually cooperate with you (this is the right strategy if e.g. you do something embarrassing in public). Sometimes you can realize that the social image you felt like you were unable to maintain, was imposed on you -- then by giving up on it, shame dissipates.
I'm not a psychotherapist but I've found it to be a personally useful perspective. It explains odd situations where I previously thought I felt shame "for no reason", and it has helped me deal productively with the emotion in my own life.
The Nocturnists, 9/2022 podcast episode “Shame in Medicine” highlights this topic with regard to the ever increasing suicidality among healthcare providers.
Excellent post. Fascinating that the loss of status is such a powerful catalyst to shame and suicide. Explains why entrepeneurs who borrow heavily from family, and then fail, are so prone to suicide.
I'm not sure what to think about the writer of this piece feeling anguished about having perpetrated shame. When I first read it I was deeply moved that a psychiatrist would speak so honestly about their impact and perceived 'unwitting' failures. The more I considered the simple mistakes in not remembering a comment made by a patient or relocating to a different town, being framed as perpetration, and contributing to suicide, the more I began to reevaluate; how helpful is this perspective for the patient and psychiatrist? The practitioner carrying the feeling of anguish in not being good enough seems to diminish their own work, not to mention the work done together with the client. If shame is to be brought to light perhaps it needs to be examined from both sides. There are people who have been victimized by blatantly, witless, dense practitioners, and they will thrill to hear your personal incrimination. However, based on your thoughtful accounts, you do not fit that type; fallible yes, but also capable of offering repair. 'An emotionally invested relationship is grounds for successful therapy' but it is not the only reason for healing. That burden or power, however you choose to look at it, resides in a mystery we cannot know; this is a requisite truth for therapist and client. Regardless of my divergent views, I look forward to reading what will no doubt be a fascinating book!
I also have been the Claire in this situation, so I’m viewing it in two minds.
I frequently hear people saying things such as, “had I not forgotten my glasses and run back inside for them that morning, perhaps the accident wouldn’t have happened?”
The butterfly effect and such.
An alternative conceptualisation would be that perhaps the accident in fact would have been far worse?
I am guilty of this myself, of course. Only now I recognise it early on and cognitively understand the flaws in what I know to be my own defence mechanism.
We strive for reason, sometimes self blame feels safer than the alternative option that we may just not have as much control of our worlds as we thought - or hoped. This applies to both chairs in the room, no matter what neutral, open stance we take, we still filter everything through our own world view.
We want to help, we want resolution for clients so we do our best in each moment that arises - to our capacity of that moment.
When we don’t live up to our expectations of ourselves, we cross the boundaries of our core values and that feels ‘icky’ so we search for meaning, search for a way of changing the experience or controlling it in the future to heal or avoid the icky feeling.
I look at shame like Claire’s, shame like my own, as burned deep in the bone marrow of our personal value systems. It becomes a part of identity that has in many ways separated or been shunned if you will, from self.
Anorexia perhaps, a subconscious presentation of one’s desperate search for their own deeply etched shame, a yearning to recover and heal the part of our identity we have lost while simultaneously denying it. You can see all the way down to our bones, yet we are still hidden.
I really admire Dr. Mahler’s post. Her willingness to be open and vulnerable is a gift. But I don’t think that shame is quite as mysterious and intractable in psychotherapy as she suggests. Many forms of psychotherapy have thoughtful approaches to shame. And I think that the idea of aiming to convert shame into guilt, while theoretically intriguing in some ways, could be harmful rather than healing.
Another brilliant guest post. Shame is indeed always so difficult to deal with in clinical practice in psychiatry and psychotherapy. During my training, it came up a few times in psychoanalytic psychotherapy and CBT supervision sessions, and also in clinical rounds in psych wards, and it was at least a bit reassuring to know that experienced clinicians struggle with it as well. The reasons why became a little clearer now.
I view shame as a learned response, in other words, conditioned. And conditioned responses can be extinguished, directly or indirectly. A client who had been working on a number of fears suddenly sat up in her chair one day and exclaimed “I just realised my shame isn’t mine. I’ve been carrying my mother’s shame all these years”. This wasn’t the theme of our work, but it was the result of it - new cognitions arising of their own volition when we no longer see the world through a particular set of conditioned responses. So I think that shame can be successfully resolved, but most likely not via psychoanalysis.
Perceptive post - thank you! I, too, am surprised by the lack of attention in the literature to shame, especially around assessment of suicide risk. Joiner's ideas about burdensomeness in suicide victims comes close, but we don't teach trainees to listen for or see shame in individuals at risk. In fact, one might wonder if our emphasis on teaching objective measures of suicide risk, as useful as they are, also serve to distance ourselves from, displace and neutralize our shame around the possibility of losing a patient to suicide.
I have found the article "The Genesis of Shame" by J. David Velleman to be insightful. It is by a philosopher, not a psychologist, but I wish it were more widely known in mental health circles.
He argues that shame is essentially just the emotional pain we feel specifically from losing control of our social self-presentation, for any reason.
This could be due to a public failure or embarrassment. But it could also happen when we accidentally reveal something neutral or positive, but that we wished to keep private. It could be due to our bodies and faces physically betraying our emotions. And it could also happen when someone else influences how other people see you socially (for example, someone who experiences racist abuse in public may feel shame even if they reject the abuse and have no respect for the racist. conversely, someone might also feel shame if they are involuntarily made the center of positive attention.)
The way to stop feeling ashamed is to regain control of social self-presentation somehow, and there are many strategies to do this. You can try to integrate/publicly accept the shameful thing (if the shame is from an actual moral failure, then this would look like going from shame -> guilt). Or you can try to ignore the shameful situation and restore your control quickly, and surprisingly people will usually cooperate with you (this is the right strategy if e.g. you do something embarrassing in public). Sometimes you can realize that the social image you felt like you were unable to maintain, was imposed on you -- then by giving up on it, shame dissipates.
I'm not a psychotherapist but I've found it to be a personally useful perspective. It explains odd situations where I previously thought I felt shame "for no reason", and it has helped me deal productively with the emotion in my own life.
The Nocturnists, 9/2022 podcast episode “Shame in Medicine” highlights this topic with regard to the ever increasing suicidality among healthcare providers.
Excellent post. Fascinating that the loss of status is such a powerful catalyst to shame and suicide. Explains why entrepeneurs who borrow heavily from family, and then fail, are so prone to suicide.
More like this! Let's destigmatize stigma.
I'm not sure what to think about the writer of this piece feeling anguished about having perpetrated shame. When I first read it I was deeply moved that a psychiatrist would speak so honestly about their impact and perceived 'unwitting' failures. The more I considered the simple mistakes in not remembering a comment made by a patient or relocating to a different town, being framed as perpetration, and contributing to suicide, the more I began to reevaluate; how helpful is this perspective for the patient and psychiatrist? The practitioner carrying the feeling of anguish in not being good enough seems to diminish their own work, not to mention the work done together with the client. If shame is to be brought to light perhaps it needs to be examined from both sides. There are people who have been victimized by blatantly, witless, dense practitioners, and they will thrill to hear your personal incrimination. However, based on your thoughtful accounts, you do not fit that type; fallible yes, but also capable of offering repair. 'An emotionally invested relationship is grounds for successful therapy' but it is not the only reason for healing. That burden or power, however you choose to look at it, resides in a mystery we cannot know; this is a requisite truth for therapist and client. Regardless of my divergent views, I look forward to reading what will no doubt be a fascinating book!
Hmm…
I also have been the Claire in this situation, so I’m viewing it in two minds.
I frequently hear people saying things such as, “had I not forgotten my glasses and run back inside for them that morning, perhaps the accident wouldn’t have happened?”
The butterfly effect and such.
An alternative conceptualisation would be that perhaps the accident in fact would have been far worse?
I am guilty of this myself, of course. Only now I recognise it early on and cognitively understand the flaws in what I know to be my own defence mechanism.
We strive for reason, sometimes self blame feels safer than the alternative option that we may just not have as much control of our worlds as we thought - or hoped. This applies to both chairs in the room, no matter what neutral, open stance we take, we still filter everything through our own world view.
We want to help, we want resolution for clients so we do our best in each moment that arises - to our capacity of that moment.
When we don’t live up to our expectations of ourselves, we cross the boundaries of our core values and that feels ‘icky’ so we search for meaning, search for a way of changing the experience or controlling it in the future to heal or avoid the icky feeling.
I look at shame like Claire’s, shame like my own, as burned deep in the bone marrow of our personal value systems. It becomes a part of identity that has in many ways separated or been shunned if you will, from self.
Anorexia perhaps, a subconscious presentation of one’s desperate search for their own deeply etched shame, a yearning to recover and heal the part of our identity we have lost while simultaneously denying it. You can see all the way down to our bones, yet we are still hidden.
Your writing is beautiful
Fantastic, thank you
What about the importance of shame in maintaining adaptive cultural stigma? Lasch wrote about the abolition of shame and its consequences for society.
I really admire Dr. Mahler’s post. Her willingness to be open and vulnerable is a gift. But I don’t think that shame is quite as mysterious and intractable in psychotherapy as she suggests. Many forms of psychotherapy have thoughtful approaches to shame. And I think that the idea of aiming to convert shame into guilt, while theoretically intriguing in some ways, could be harmful rather than healing.
Another brilliant guest post. Shame is indeed always so difficult to deal with in clinical practice in psychiatry and psychotherapy. During my training, it came up a few times in psychoanalytic psychotherapy and CBT supervision sessions, and also in clinical rounds in psych wards, and it was at least a bit reassuring to know that experienced clinicians struggle with it as well. The reasons why became a little clearer now.
Thank you, Susan and Awais.