Some years ago I sat with other attending clinicians in the tiny, one-window office of Joan Turkus, then medical director of “The Center” at the Psychiatric Institute of Washington, lamenting the density and intractability of shame in our chronically traumatized patients. The gist was, in essence, a plea: “How in the world can we make any headway with shame that seems more like solidified glue than a feeling?”
And it wasn’t that our patients didn’t know about the hardened molasses in which they felt embedded. Some of my own patients tenaciously battled to hold on to their belief of being “a worthless failure, like sludge at the bottom of the drain,” and “undeserving of any kindness.” Why was this shame not only adherent but also held in a desperately clenched fist? It was easy to get caught in a totally non-productive argument about whether or not somebody was shameful. The hope of curing patients by exhortation was abandoned early on. What was going on? Why was this part of this already impossible work, so especially difficult?
I’ve learned to think of shame as part of a spectrum of feeling— embarrassment, shame, humiliation, mortification—and to understand that shame is different than guilt. Why the spectrum? Feeling shame because you judge yourself inadequate or a failure, seems to have qualitative differences and implications from the shame and humiliation resulting from the explosiveness of sadistic abuse. An example of the latter is the shame incurred when the person abusing you calls you a whore and slut, sexually stimulates you, and then in the throes of your visible orgasm tells you again that you’re a whore because who else would enjoy what they did to you? Humiliation is the intentional infliction of shame. Embarrassment is a mild cousin, in general. Mortification is shame at the level of wanting to die in the moment of shaming. Guilt doesn’t weigh in about self-worth; it’s about regretting something you’ve done that you believe is a bad thing, but you, the person, remain intact.
But we ought not stop here in considering the spectrum of shame. We should also include contempt and grandiosity, both reactions to actual or potential shaming and loss of face/self. Contempt is a highly efficient tool. It makes clear to the target your intent to humble them. You hold their strength as pitiful and amounting to nothing in the face of your power. You make clear that your response to their challenge will crush them.
Two additional shame-related emotions are dissmell and disgust. Dissmell was the brainchild of Sylvan Tomkins who likened this to the twisted upturned nose and the facial grimace associated with declaring someone to be “a stinker,” “to stink to high heaven.” Disgust is just what it sounds like, the wish to spit out or vomit up what has been taken in because it is putrid. “You disgust me” is as painful a generator of shame as any expression of revulsion.
Why include contempt, dissmell, and disgust along with the shame spectrum of emotion? The bottom line is that it is sadly all too typical for a person laden with shame also to express contempt for themselves, self-disgust, or to think of themselves as being treated as if they stink. This kind of eviscerating self-regard is painful to hear and often feels impossible to challenge in the context of what feels like rock-solid conviction of beliefs about self as less than worthless.
The shame spectrum of emotion also teaches us the extent to which physiology and affectivity are highly linked. An affect is the unconscious physiologic stirrings out of which emerges the felt sensation we call a feeling and to which we assign the word of a named emotion, if it fits in with the library of named emotion experiences.
All this sounds complicated, and it’s also true that when dissociative processes are active, things are exponentially much more difficult for the patient and clinician. When there is dissociative numbing, people behave as if they are ashamed but have no contextual appreciation that this is what they are doing; they want to hide, and do, but don’t know why, for example. In dissociative identity disorder, self-regulation may paradoxically be enforced through internal ridicule between self-states, threat, shaming, humiliation, and re-enactment of past traumatic experience in which a person finds they are waking up once again in the bed of a sadist but without memory of how they got there. Having that awakening in the middle of a painful sexual act can be terrifying. The loss of self-control is deeply humiliating, especially as it happens again, and again, without explanation. There is more to this kind of sexual addiction than may initially be understandable given the underlying dissociative mechanisms at work.
To really understand how to work with this level of shame and associated toxic emotional intensity requires a clinical example and spelling out some principles by which an approach can be negotiated. I will provide that for you in a future installment of this blog. Meanwhile, if you’d like to do some additional reading on the subject, check these resources out on the web or in the library:
Bromberg, P. M. (2001). Out of body, out of mind, out of danger: Some reflections on shame, dissociation, and eating disorders. In J. P. a. C. Stuart (Ed.), Hungers and Compulsions: The Psychodynamic Treatment of Eating Disorders & Addictions (pp. 67-80). New York: Jason Aronson.
Broucek, F. J. (1982). Shame and its relationship to early narcissistic developments. International Journal of Psychoanalysis, 63, 369-378.
DeYoung, P. A. (2015). Understanding and Treating Chronic Shame: A Relational/Neurobiological Approach: Routledge.
Dorahy, M. J. (2010). The impact of dissociation, shame, and guilt on interpersonal relationships in chronically traumatized individuals: A pilot study*. Journal of Traumatic Stress, 23(5), 653-656.
Kessler, B. L., & Bieschke, K. J. (1999). A retrospective analysis of shame, dissociation, and adult victimization in survivors of childhood sexual abuse. Journal of Counseling Psychology, 46(3), 335.
Lansky, M. R. (1992). Fathers who Fail: Shame and Psychopathology in the Family System. Hillsdale, NJ: The Analytic Press.
Lewis, H. B. (1987). The Role of Shame in Symptom Formation. Hillsdale, N.J.: Lawrence Earlbaum Associates, Inc.
Nathanson, D. L. (1992). Shame and Pride: Affect, Sex, and the Birth of the Self. New York: W.W. Norton & Company.
Pulver, S. E. (1999). Shame and guilt: A synthesis. Psychoanalytic Inquiry, 19(3), 388-406.
Scheff, T. J. (1988). Shame and conformity: The deference-emotion system. American Sociological Review, 395-406.
Scheff, T. J., & Retzinger, S. M. (2000). Shame as the master emotion of everyday life. Journal of Mundane Behavior, 1(3), 303-324
Tangney, J. P., Miller, R. S., Flicker, L., & Barlow, D. H. (1996). Are shame, guilt, and embarrassment distinct emotions? Journal of Personality and Social Psychology, 70(6), 1256.
Wille, R. (2014). The shame of existing: An extreme form of shame. The International Journal of Psychoanalysis, 95(4), 695-717.
Wurmser, L. (1994). The Mask of Shame. Northvale, N.J.: Jason Aronson.
Richard A. Chefetz, M.D. is a psychiatrist in private practice in Washington, D.C. He was President of the International Society for the Study of Trauma and Dissociation (2002-3), Co-Founder and Chair of their Dissociative Disorders Psychotherapy Training Program (2000-2008, and is a Distinguished Visiting Lecturer at the William Alanson White Institute of Psychiatry, Psychoanalysis, and Psychology. He is also a faculty member at the Washington School of Psychiatry, the Institute of Contemporary Psychotherapy & Psychoanalysis, and the Washington Center for Psychoanalysis. He is a Certified Consultant at the American Society of Clinical Hypnosis, and is trained in Level I and II EMDR. Dr. Chefetz was editor of “Dissociative Disorders: An Expanding Window into the Psychobiology of Mind” for the Psychiatric Clinics of North America, March 2006, “Neuroscientific and Therapeutic Advances in Dissociative Disorders,” Psychiatric Annals, August 2005, and “Multimodal Treatment of Complex Dissociative Disorders,” Psychoanalytic Inquiry, 20:2, 2000, as well as numerous journal articles on psychodynamic perspectives on trauma, dissociation, and clinical process. He recently published a book with Norton (2015), in their Interpersonal Neurobiology series, Intensive Psychotherapy for Persistent Dissociative Processes: The Fear of Feeling Real.