In my previous blog posts, I discussed the difference between shame and guilt; both of which are painful, self-evaluative affects. Guilt involves the evaluation of a specific behavior and therefore, offers the opportunity for reparation. If Gary fails a test and feels guilty, he believes he can do things—like study harder—that will relieve some of his guilt. Even the thought that he is able to do something, alleviates some of the distress from his self-evaluation.
If Gary perceives himself to be a loser who can never do anything right, then he is experiencing shame. Although shame can be transient, there are people whose experience of shame (shame-proneness) is pervasive; meaning that at the very core of their sense of self is the feeling of being small, insignificant and/or bad.
In my most recent blog post in this series, I discussed how shame-proneness compromised empathy, causing conflict and turmoil in relationships. Another lasting and painful consequence of unresolved shame is shame-based depression.
Depression is at best, an umbrella concept, not easily understood or reducible to a diagnostic label. Just because people share symptoms does not mean the cause is the same. Think of all the different underlying reasons for a headache. If we are to hope for good psychotherapy outcomes, we need to understand the causes of the symptoms, not an easy endeavor with distress as broad as depression.
When depression is shame-based, it is not only the symptoms that debilitate, but also the ingrained belief that the person does not deserve to feel better. Because fundamentally they feel bad, small, unimportant, the suffering feels congruent. Relief feels foreign and undeserved. If the shame basis of the depression is left unidentified, improvement will be a tortuous, uphill battle for both you and your patient.
Take Madeline (an amalgam of patients suffering from shame-based depression), for example. She’s a 39-year-old woman who came in for depression and reported a lifelong history of related symptoms. She described apathy, anhedonia, problems with motivation and concentration, appetite and sleep disturbances as well as feelings of worthlessness. As the therapy progressed over the first year, it became clear that Madeline experienced deep-rooted and chronic shame.
She regarded herself as unintelligent, unattractive and uninteresting. In response to these feelings, she developed grandiose aspirations to compensate for her supposed deficiencies that no one could ever live up to. Consequently, she experienced continuous and inevitable failures which confirmed and perpetuated her shame-narrative.
“I’ll never be intelligent. Everyone knows more than me,” she said, averting my gaze.
“Can you tell me more about that?”
“I need to read every single book on a particular topic before I’ll feel knowledgeable enough to have a conversation about it.”
“Does that seem a realistic endeavor?”
“I have to. It’s the only way I’ll feel smart enough,” she said flatly, fighting a frown.
“I worry that you are setting yourself up to fail by having expectations that are impossible to reach.”
“I never meet any of my goals, anyway.” She crossed her arms.
“You’ll never find a feeling of accomplishment or meaning if you keep setting insurmountable goals. I’d like to understand why you’re doing that. What would happen if we worked together to set realistic goals, things you can accomplish?”
“Well, then I might feel better.” She released a sarcastic laugh. “I wish that was a joke. I don’t feel like I deserve to feel better.”
“Tell me more about that.”
“No one ever supported me or any of my interests. I was told I wasn’t good enough. And it’s the truth, isn’t it? Look at my life. I’ve done nothing to be proud of. Failed at everything I ever tried or ever wanted.”
After I better understood her shame, I realized that despite our seemingly strong relationship, Madeline continually undermined the therapeutic process. Every time she started to feel better, she’d set these impossible standards, which ultimately confirmed her feelings of not being good enough, of being a failure. Of not deserving any relief.
Madeline knew nothing but her depression. She held onto it as if without it she would descend into an unfathomable void without it. When patients have a history of emotional abuse, as she did, where disparaging statements are woven through the fabric of their identity, the depression is often shame-based. And the treatment is extremely challenging. We have to help our patients to find ways to question, then challenge and finally close the book on their shame-narrative.
To some degree, all depressions contain an element of shame. But in Madeline’s case, it was pervasive, evolving more like a personality trait than a cluster of symptoms, making it harder to treat. Her shame caused her to perpetuate her own distress.
I combined humanistic, psychodynamic and cognitive-behavior therapy for Madeline. Psychodynamic, to help her understand how the shame evolved through her childhood experiences of emotional abuse; humanistic to focus on helping her identify and foster the many strengths she did have and to help her find meaningful pursuits where she could feel her endowments; cognitive-behavioral to help her with her thought distortions. I had her keep a journal of the false narratives. Every time she had an experience that disconfirmed them, I had her write it down. For example, she thought no one liked her and as a result, she was socially isolated. Every interaction where someone complimented her or showed interest in her, every time someone asked her for advice, she wrote it down. This was to reinforce different statements about who she was.
The more Madeline discovered her unique strengths and used them and felt them, the better she became at recognizing the falseness of her narratives. And the more she understood the distortions, the better she became at pursuing goals that were attainable.
I also did some psychoeducation in the second year of our treatment. I explained the shame and tried to help her understand her depression. Madeline had become curious and open and was able to introspect even in areas that were very painful.
Madeline developed an observing ego. She became more cognizant of her distortions and began to question their validity. In order to help patients recognize their shame, we need to listen closely to these narratives. We need to identify the shame. And then, we can adjust our therapeutic techniques to meet our client’s unique needs. We need to believe they deserve to get better and can get better, even when they are undermining every step of the process. But for the deepest and most lasting change to occur, they need to believe in a narrative free of shame.
File under: The Art of Psychotherapy
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If Gary perceives himself to be a loser who can never do anything right, then he is experiencing shame. Although shame can be transient, there are people whose experience of shame (shame-proneness) is pervasive; meaning that at the very core of their sense of self is the feeling of being small, insignificant and/or bad.
In my most recent blog post in this series, I discussed how shame-proneness compromised empathy, causing conflict and turmoil in relationships. Another lasting and painful consequence of unresolved shame is shame-based depression.
Depression is at best, an umbrella concept, not easily understood or reducible to a diagnostic label. Just because people share symptoms does not mean the cause is the same. Think of all the different underlying reasons for a headache. If we are to hope for good psychotherapy outcomes, we need to understand the causes of the symptoms, not an easy endeavor with distress as broad as depression.
When depression is shame-based, it is not only the symptoms that debilitate, but also the ingrained belief that the person does not deserve to feel better. Because fundamentally they feel bad, small, unimportant, the suffering feels congruent. Relief feels foreign and undeserved. If the shame basis of the depression is left unidentified, improvement will be a tortuous, uphill battle for both you and your patient.
Take Madeline (an amalgam of patients suffering from shame-based depression), for example. She’s a 39-year-old woman who came in for depression and reported a lifelong history of related symptoms. She described apathy, anhedonia, problems with motivation and concentration, appetite and sleep disturbances as well as feelings of worthlessness. As the therapy progressed over the first year, it became clear that Madeline experienced deep-rooted and chronic shame.
She regarded herself as unintelligent, unattractive and uninteresting. In response to these feelings, she developed grandiose aspirations to compensate for her supposed deficiencies that no one could ever live up to. Consequently, she experienced continuous and inevitable failures which confirmed and perpetuated her shame-narrative.
“I’ll never be intelligent. Everyone knows more than me,” she said, averting my gaze.
“Can you tell me more about that?”
“I need to read every single book on a particular topic before I’ll feel knowledgeable enough to have a conversation about it.”
“Does that seem a realistic endeavor?”
“I have to. It’s the only way I’ll feel smart enough,” she said flatly, fighting a frown.
“I worry that you are setting yourself up to fail by having expectations that are impossible to reach.”
“I never meet any of my goals, anyway.” She crossed her arms.
“You’ll never find a feeling of accomplishment or meaning if you keep setting insurmountable goals. I’d like to understand why you’re doing that. What would happen if we worked together to set realistic goals, things you can accomplish?”
“Well, then I might feel better.” She released a sarcastic laugh. “I wish that was a joke. I don’t feel like I deserve to feel better.”
“Tell me more about that.”
“No one ever supported me or any of my interests. I was told I wasn’t good enough. And it’s the truth, isn’t it? Look at my life. I’ve done nothing to be proud of. Failed at everything I ever tried or ever wanted.”
After I better understood her shame, I realized that despite our seemingly strong relationship, Madeline continually undermined the therapeutic process. Every time she started to feel better, she’d set these impossible standards, which ultimately confirmed her feelings of not being good enough, of being a failure. Of not deserving any relief.
Madeline knew nothing but her depression. She held onto it as if without it she would descend into an unfathomable void without it. When patients have a history of emotional abuse, as she did, where disparaging statements are woven through the fabric of their identity, the depression is often shame-based. And the treatment is extremely challenging. We have to help our patients to find ways to question, then challenge and finally close the book on their shame-narrative.
To some degree, all depressions contain an element of shame. But in Madeline’s case, it was pervasive, evolving more like a personality trait than a cluster of symptoms, making it harder to treat. Her shame caused her to perpetuate her own distress.
I combined humanistic, psychodynamic and cognitive-behavior therapy for Madeline. Psychodynamic, to help her understand how the shame evolved through her childhood experiences of emotional abuse; humanistic to focus on helping her identify and foster the many strengths she did have and to help her find meaningful pursuits where she could feel her endowments; cognitive-behavioral to help her with her thought distortions. I had her keep a journal of the false narratives. Every time she had an experience that disconfirmed them, I had her write it down. For example, she thought no one liked her and as a result, she was socially isolated. Every interaction where someone complimented her or showed interest in her, every time someone asked her for advice, she wrote it down. This was to reinforce different statements about who she was.
The more Madeline discovered her unique strengths and used them and felt them, the better she became at recognizing the falseness of her narratives. And the more she understood the distortions, the better she became at pursuing goals that were attainable.
I also did some psychoeducation in the second year of our treatment. I explained the shame and tried to help her understand her depression. Madeline had become curious and open and was able to introspect even in areas that were very painful.
Madeline developed an observing ego. She became more cognizant of her distortions and began to question their validity. In order to help patients recognize their shame, we need to listen closely to these narratives. We need to identify the shame. And then, we can adjust our therapeutic techniques to meet our client’s unique needs. We need to believe they deserve to get better and can get better, even when they are undermining every step of the process. But for the deepest and most lasting change to occur, they need to believe in a narrative free of shame.
File under: The Art of Psychotherapy