TIFT #9 What You Don't Know About Shame

Here’s the secret:

Treating inappropriate shame is one of the hardest jobs in psychotherapy. Knowing this and understanding why will help you know what to do and how to manage expectations. The surprising thing is that, as far as I can tell (and I’d love to know otherwise) no one has noticed how different shame and guilt are from other pathologies. 

I believe the reason comes from the culture of the 60s. That’s when we all decided that sin didn’t exist and that the conscience was passé. There is almost no psychological literature on the conscience since then, and what there is comes from areas like criminal justice and sociology. So it’s time for us to take a look at the conscience and how it functions.

The Infrastructure of Shame

Most people who have written about shame have stopped at the idea that it is learned. And they treat that learning as basically the same as any other learning such as the schemas that shape our interpersonal responses or our likes and dislikes. This is far from the truth, and clinically it makes a big difference. So, then where does shame come from?

The Source of Shame

Shame is not a direct response the way fear or anger are. It is the result of a process of subjecting some aspect of reality to a judgment. When reality does not meet a standard, then out comes shame or guilt. Clinically this makes a big difference. When we treat fear, say coming from a traumatic experience, we want the patient to experience the fear in a context of safety then, hopefully, the mind learns that the fear is unfounded, and the patient is no longer afraid. If we do that with shame, bringing out the feeling in a safe context, there might be a slight reduction, but overall there is little change. Why? It’s because to change shame, we need to change not only the emotion but the standard on which the judgment was made and which, in turn, led to the emotion. That is fundamentally different from how we heal fear or anger.

And By the Way...

Shame doesn't work like any other emotion. Most emotions have a primitive source in the limbic system where the anatomical structures and responses they produce are closely analogous to those of other mammals. Shame is different. It originates in the cortex, right where one would expect the brain to house the apparatus of standards and judgment.

Shame and Anorexia Nervosa

Let’s look at an example that will surprise you. When anorexics do the right thing and follow their treatment team’s urging to eat, what do they feel? Intense shame. They feel gross and ugly and horribly ashamed for having eaten. That’s because they are carrying a pathological standard that says eating is bad! Imagine that you sit with the patient and show them that it really isn’t shameful to eat. Do you think that will have the same level of effects as sitting with a patient who is afraid? NO! Instead, you will need to work on the standard and that is much harder than correcting an ordinary belief such as the belief that feeling good will lead to something bad happening.

The Conscience

In the popular portrayal, Jimmy Cricket, the conscience on your shoulder, is always right and will gently hold firm to what’s right, even if you try to talk him out of it. The truth is that the conscience can be wrong. It still holds extremely tightly to its standards, but, as in the case of anorexia or the case of low self-esteem after sexual trauma, these standards can be dead wrong.

Secret Infrastructure

The secret is that the standards that are the basis of judgments, and therefore shame, are better described as internalized, rather than learned. Internalized means they become a permanent part of our makeup. Two lines of evidence show how permanent they are. First, in toilet training, cleanliness becomes an internalized standard. When elderly people soil themselves involuntarily, they still feel shame. The standard is still in place a lifetime later. The second piece of evidence is that the low self-esteem of trauma survivors, even if overcome at great effort, will quickly return after a series of adverse events.

Since there has been, to my knowledge, little interest in research in this vital clinical phenomenon, I can only give my working hypothesis about the basis of internalized standards. I believe the trigger for internalization is attachment anxiety. Prospective cult members, children needing to be loved and accepted in their family, and people experiencing the terrible loneliness of being abused tend to identify with the beloved or the aggressor out of a need for connection. Once internalized, the standards are permanent.

Clinical Implications You Should Know

What this means for us clinicians is that the only way to counteract a pathological standard is to instill a new, healthier standard and to encourage the patient to give it precedence over the old, unhealthy one. That’s why my dictum in this case is “Everything but the Kitchen Sink.” Everything we can think of, and then we need to be honest with ourselves and our patients that this will still require hard work and maintenance after therapy is ended. In particular, treatment starts with a very clear intellectual understanding that the conscience in this case is pathological and that the unhealthy standard needs to be traded in. Next, successful treatment requires that behavior must change. As long as the patient allows the standard to govern behavior, then the wrong standard is reinforced and positive change will be blocked. One way to describe purposefully going against unhealthy standards is “civil disobedience,” one of the most important treatment tools.

I hope next time you notice pathological shame, you will think of the conscience with its infrastructure and fallible standards. And I would love to hear that there are others who have made the same observations and, even more interesting, have done research on them.

Jeffery Smith MD