Working with Shame in Psychotherapy

When the idea first came to write about “working with shame in psychotherapy” it took me a little while before I realised there were several ways this title could be interpreted. Was I going to talk about the affect of shame within our patients, and ways of therapeutically responding to it, or was I going to speak of ourselves as therapists being ashamed of what we do? The latter may sound jocular at first, but it is really not so, for, as you will hear, I regard shame within the therapist as requiring as much attention as shame within the patient.

Then when I began to gather my thoughts on shame, I was aware that I was going to have to speak predominantly from one particular theoretical vantage point, that of self psychology. This limitation, if indeed it is a limitation, arises partly from of my having been exposed to self psychological thinking during my psychoanalytic training in Canada, with the Toronto Psychoanalytic Institute, but also because the topic of shame itself is one which self psychological writers have paid particular attention to.

Indeed, before beginning the paper I consulted the collected papers of Melanie Klein and, a little surprisingly, I found the word “shame” does not appear in the Index. This is not to say that the British object relations writers have neglected the topic. Far from it. But they do not seem to have elaborated their ideas to the degree that Kohut and his colleagues and successors have done. Neville Symington, in “Narcissism -- A New Theory”, remarks, “Shame is the emotion we experience when we become aware of the parts of ourselves that are not integrated.” He goes on to say, “Shame is closely related to certain aspects of narcissism because one thing that we all do, to the extent that we are dominated by narcissistic currents, is to hide particular sources of action” (Symington 1993).

Since one of the tasks in psychotherapy is to understand hidden sources of action, it follows that the process itself inevitably provokes feelings of shame. Symington’s definition of shame is not a detailed one but it is compatible with the formulations Kohut put forward in his paper “Thoughts on Narcissism and Narcissistic Rage” (Kohut 1972). Kohut suggested that shame and narcissistic rage are closely related phenomena. Shame arises when exhibitionistic impulses are mobilised in the expectation of approval from a mirroring selfobject. When this response does not eventuate the ego is disrupted in its capacity to regulate the flow of these impulses. On the one hand it yields to the pressure while, on the other hand, it desperately attempts to stop the flow. This has its physiological equivalent in the blushing response, with alternating flushing and blanching of the skin.

Kohut suggested that “while the essential disturbance underlying the experience of shame concerns the boundless exhibitionism of the grandiose self, the essential disturbance underlying rage relates to the omnipotence of this narcissistic structure. The grandiose self expects absolute control over a narcissistically experienced archaic environment.” If this control is experienced as failing, there is a similar disruption in the capacity to regulate, with the mixed flooding and blocking of aggression that characterises narcissistic rage.

Symington’s comment, “Shame is the emotion we experience when we are aware of the parts of ourselves that are not integrated”, seems to encompass both experiences -- the painful exposure and the failure to exert a desired control.

One central, and controversial, aspect of Kohut’s theorising was his proposal that narcissism was not, as Freud earlier suggested, a developmental stage somewhere between auto-erotism and object love, but that it had its own line of development in parallel with that of object love. If we allow these metaphors to be provisional and playful, as Kohut himself said he wished to do, we may find them helpful in our understanding of shame.

Kohut suggested that we could think of the development of narcissism as proceeding along two lines -- those of grandiosity and idealisation (Kohut 1971). In the archaic infantile state the child expects to be the centre of the mother’s gaze and thought. She is to be the mirroring selfobject. Simultaneously, she is experienced as an omnipotent source of strength and nourishment who, by allowing for merger, enables the child to feel safe. In that respect she is the idealised selfobject.

While in healthy development these archaic states become modulated and part of an internal world that allows for mature ambitions and ideals, selfobject frustrations inevitably mean that particles of these archaic structures will continue to exist, to a greater or lesser extent. Their exposure will provoke shame.

Kohut stated the shame of narcissistic subjects was "due to a flooding of the ego with unneutralised exhibitionism and not to a relative ego weakness vis-à-vis an overly strong system of ideals" (1971, p.181n). That is, he focused upon a fragile self being overwhelmed by the frustration of mirroring needs. He gradually abandoned the traditional analytic view of shame as resulting from the failure to live up to the ego ideal, since this concept was grounded in classical drive theory. However, Morrison (1989) pointed out that Kohut replaced this with his observation on the need of the self for accepting responses from an idealised selfobject and/or the need of the self for an idealised selfobject with which it may safely merge. The following vignettes place shame in the context of painful exposure of these archaic mirroring or idealising needs.

Shame via exposure of the archaic grandiose self:

Mrs A came to analysis with a number of disabling fears about herself. One was that she was so severely damaged that no analyst would accept her as a patient. She came from an abusive family and had been subjected to particular humiliation for ever wanting anything for herself. She found it extremely difficult to use the couch. Mostly she would sit in the chair in front of the analyst and cover her face. It took a verbal invitation from the analyst, indeed several, before she would even sit on the couch, and then she remained bolt upright in what was obviously an uncomfortable position. In one session the analyst invited her to lie down on the couch and this time she did. What followed was remarkable in that this highly defended patient began to express tender fantasies of being a “princess” and a special person in the analyst’s mind. But the evening after that session she rang the analyst at his home, something she had never done previously, and told him she felt so furious and humiliated she never wanted to come back again. She said he had exposed her in a cruel manner and she felt “raped”.

The interpretive work in the subsequent session centred upon the painful exposure of her infantile longing to be the special princess in the eyes of her parents, a longing which had been disavowed rather than integrated but was now being elicited within the transference. For a considerable time after that she was still unable to lie down on the couch unless explicitly invited by the analyst. To do so without such an invitation, to presume that it was her right, felt like an arrogance that was unbearably shameful to her. She attempted to modulate the archaic impulse by means of humour. She frequently described her own extreme sensitivity to narcissistic injuries, and said she felt like “the princess and the pea”, referring to the children’s story about the princess who couldn’t sleep because, although she was lying on several mattresses, there was a dried pea on the one at the bottom of the pile. The fact that she could be perturbed by subtle irritants, through so many mattresses, was proof that she was a real princess. Subsequent work enabled this “princess” fantasy to be reformulated in terms of her need to curl up as an infant within the analyst’s care.

Shame via exposure of the need for the idealised selfobject:

Mr B sought analytic help because of a prolonged difficulty in establishing intimate relationships. He was a lawyer who was quite successful in his work. He had indeed enjoyed a sexual relationship with a young woman when he was an adolescent, but that finished when he went to university. Thereafter he had a number of relationships in which there was no intercourse. He felt frightened of intimacy and paralysed by his Catholic scruples.

He described his mother as depressive and demanding. His father was an impulsive, violent man. The patient was the youngest of four siblings and, while he was sometimes subjected to brutal bashings, they were less frequent and violent than those meted out to his older brothers. The parents’ marriage eventually broke up and the father would have nothing to do with any of his children.

Early in the analysis Mr B took a long time to pay the analyst’s bills. When his attention was drawn to this he switched to an apparent compliance, paying each bill immediately he received it. He established a more intimate relationship with a young woman, but was often late for his analytic sessions. When the analyst wondered what this was about, the patient became withdrawn and stubborn and had no thoughts to offer. At one point he remarked that he had spent most of his life pleasing other people, and he saw no point in pleasing the analyst by saying what was on his mind. He found most of the analyst’s interventions useless. Silences were persecutory but when the analyst did speak the patient would often respond with “You’re not saying anything.” He felt he was being left alone to do his own analysis, just as his parents had left him to bring himself up.

His constant devaluation of the analyst provoked a countertransference rage which, on one occasion, the analyst was able to process well enough to say, “I feel you’re trying to get me to thrash the daylights out of you, and maybe if I do that you can feel you really do have a father.” The patient’s response was to feel overwhelmed with painful longing, which he was able to acknowledge.

But the frequent lateness did not alter until the analyst finally told him, “This is quite unacceptable. Unless you can get here on time for your sessions I’m going to terminate the analysis.” Mr B’s response was, “Thank God. Someone’s in charge here. Someone’s making some rules.” Not unexpectedly, these rules had to be frequently restated and the patient continued to test the limits. But some clarity did emerge around the meaning of the lateness. His father had often prohibited certain activities as dangerous. Mr B wondered if this were really so or if his father was just being authoritarian. So he went ahead and did the things his father had told him not to and his father took no notice but would eventually become threatening and bullying again. Mr B concluded his father didn’t really believe the activities were dangerous, and was thus being untruthful with him, or else he did believe it but didn’t care enough about him to take firm protective action. At the core of the transference was an archaic idealisation, a longing for a fatherly strength and reliability that was so intense he was ashamed to expose it. His disappointment when the analyst did not live up to this ideal was such that he felt enraged with the analyst and humiliated by his own need. An interpretation that acknowledged this disappointment was greeted with relief.

With such a patient, it is the interpretive working through of his frustration in his archaic transference longings that allows for the strengthening of internal structure, in the form of a more benevolent superego and a diminished vulnerability to shame.

Shame via the exposure of fragmentation products:

Kohut suggested that sexualisation and aggression within the transference were less likely to be unmodulated drive derivatives than “fragmentation products” signalling the rupture of a needed self-selfobject bond. Mr B’s rage when he experienced his analyst as failing to respond to his idealising needs is a good example of this. I believe the “perverse relationships between parts of the self” described by Kleinian writers such as Herbert Rosenfeld (1964) and John Steiner (1982) are another way of describing this internal fragmentation. My own theoretical bias, similar to that of analytic writers like John Bowlby, Ronald Fairbairn and Heinz Kohut, is to view attachment needs as primary and regard destructiveness and perversity as resulting from early frustration of such needs. But when fragmentation products become conscious they are a potent stimulus to shame since, as Symington observed, they make us aware of our lack of integration.

Mrs C came into analysis describing a life-long depression. She regarded herself as the baby her mother should have aborted. Her mother had left her first husband to be with the patient’s father after the affair which resulted in her conception, but the second marriage was a miserable one. The father was physically violent and dominated by persecutory anxieties while the mother seemed depressed and helpless. Mrs C’s own first marriage had produced a child but ended in divorce. Her second marriage seemed more companionable, but there was evidence of profound depressiveness within the husband and it seemed Mrs C took most of these projections into herself in order to maintain an idealised view of the relationship.

Early in the analysis she experienced an intense yearning to be with the analyst, and found this a cause for shame. “It’s like I have to have you on an intravenous drip.” Later there were sessions in which she was frozen into silence. This went on for several weeks. What little she could bring herself to say seemed lifeless. Eventually she said, “I have to talk to you about my thoughts because if I don’t I can’t talk about anything else.” Gradually she acknowledged being preoccupied with sexual fantasies about the analyst and herself. “We’re having sex and you’re being very cruel and violent to me. The really horrible part is, the more cruel you become, the more exciting I find it.”

The analyst responded, “I think perhaps these fantasies express how desperately important it is for you to feel close to me, and when you were a child with your family violence and cruelty must have seemed the most reliable way for people to really be in contact with each other.” She replied sadly, “It was the only way.”

This interpretation was part of a process in which her perverse preoccupations could begin to recede, allowing for a clearer focus on her need for a deep emotional bond with the analyst, and the shame she experienced about that. The frustration of her longing to experience her parents as idealised selfobjects -- as adequate “containers”, to use Bion’s term -- had left her vulnerable to the shameful and frightening conviction that her love was destructive. What we might call “the schizoid equation” declares, “Need equals Greed equals Being Bad.”

Shame in the countertransference:

This is a vast topic worthy of several papers in itself. We are all familiar with the differentiation between shame and guilt propounded by classical theory -- that guilt is the affect experienced when the ego is under punitive attack from the superego, while shame is what we encounter when the ego fails to live up to the expectations of that segment of the superego we call the ego ideal. This was the formulation proposed by Piers and Singer (1953) in their book “Shame and Guilt”, based on the earlier writings of Freud. As therapists we have particular ideals of therapeutic behaviour and our inevitable failures to fully live up to them bring the constant threat of shame. For example, Mr B’s analyst was not always able to process the patient’s denigration as helpfully as in the interpretation quoted in the vignette. Sometimes he reacted with a denigratory rage of his own, that is, he reacted rather than responded to the patient, and this was a source of shame for the analyst.

But there is another level of shame response in the countertransference that is less widely recognised. I refer to the effect of the patient’s archaic transference longings of mobilising painful fragments of archaic narcissism within the analyst, and there is no-one so empathically brought up or well analysed as not to have such fragments available somewhere. Kohut noted that one of the reasons Freud gave for asking patients to lie on the couch was that he didn’t like being stared at hour after hour. Yet while the gaze of patients towards their therapists can often be hostile, experience tells us this is usually not the case. More often, the patient comes with the urgent expectation that this person can be helpful in the patient’s experience of psychic pain. That is, there is an idealising transference that, in the depths of the unconscious, may have archaic, omnipotent dimensions. This can be painfully over-stimulating to elements of split-off archaic grandiosity within the therapist, bringing the threat of shame and causing the therapist to unconsciously turn away from the patient’s transference needs. Perhaps one partial solution may be to ask the patient to lie on the couch and stare at the ceiling instead of the therapist.

In my teaching work with psychiatrists in training, and other therapists early in their careers, I find this counter-transference embarrassment to be one of the commonest resistances to deep empathic contact. Many years ago, in a psychiatric hospital in London Ontario, Canada, I supervised the therapy of a suicidal borderline adolescent girl conducted by a young female social worker. The social worker was indeed a gifted therapist with an intuitive empathic capacity, and the patient responded very favourably to the prolonged work they did together. But I vividly remember the social worker coming to my office one day for a supervision session and exclaiming, “What do I do with this? Suzie tells me that I’m her whole life, I’m the only thing that keeps her alive, and she’d be dead without me. What do I do?” I told her, “You don’t do anything, because it’s true. You just keep on the way you’ve been going.”

Yet from my own experience I could easily identify with the social worker’s anxiety over the immense responsibility the patient was placing with her and also, at a much deeper level, with her shame anxiety over the stimulation of archaic grandiosity. Some years earlier I had myself been treating a seriously disturbed woman, the victim of childhood sexual abuse who had intermittently suffered brief psychotic episodes prior to coming into therapy, and also on several occasions during the therapy. I had some interest in self psychology back then, but I didn’t have much of a grasp on the theory. In retrospect I realise that the analyst I was seeing at the time was part of a group meeting regularly with Kohut in Chicago and this undoubtedly had an effect upon me, though quite properly he wasn’t discussing theoretical issues in the sessions. My first detailed exposure to the theory came when Paul Ornstein, a friend and collaborator of Kohut’s, came to London Ontario and gave a discussion on the development of Kohut’s thought. It was basically the same paper as he subsequently used as the Introduction to “The Search for the Self”, the selection of Kohut’s papers edited by Ornstein which was published in 1978.

I was particularly interested when Ornstein spoke of the archaic idealising transference, because Kohut regarded this as a phenomenon in its own right and not necessarily a defensive manoeuvre against destructive envy. Ornstein said that the therapist’s failure to empathically acknowledge archaic idealisation frequently resulted in painful therapeutic stalemates. This set me to thinking about my own patient, with whom I’d been having a very difficult time, and perhaps that was because I’d been overlooking the very thing Ornstein was talking about. The next time I saw her she was discussing the Arizona vacation she and her husband were about to take. This was in the depths of the Canadian winter. There was a metre of snow on the ground and the daily temperature hovered around minus 15 degrees, so an Arizona desert resort seemed a very sensible destination. She spoke of her previous vacation there, and described the warmth and purity of the air and the majestic colouring of the rocks.

It would have been very easy to interpret negative transference, and comment on how attractive it must be to get away to such a place, away from the miserable cold of her home town and the therapist who seemed of such little use. But I didn’t. I thought instead of the archaic idealising transference and an interpretation came to my mind that seemed so full of my own archaic grandiosity that I thought at first, “I can’t possibly say that!” But I took a deep breath and said to her, “I think you are saying that you would like to be able to find the same majesty, warmth and colour in me also, and to feel at home with me as you do in the landscape of Arizona.” Her eyes filled with tears and she answered, “I’ve been wanting to say that to you for such a long time, but I didn’t dare.”

Her response to that interpretation was one of the pivotal points in her therapy and also, I believe, in my own development as a therapist. Certainly the crucial affect she had been struggling with was shame, related to the non-recognition of her idealising needs. She was compelled to cover over what she “didn’t dare” reveal. And the acceptance in depth that was so important to her could come about only after the therapist’s own struggle with shame anxiety.

Discussion

So far, I have kept fairly closely to Kohut’s metaphors, examining shame related to exposure of archaic grandiose or idealising needs within the patient, and their potential to activate similar archaic states within the therapist. And I have linked them together through the comment of Neville Symington that “shame is the emotion we experience when we are aware of the parts of ourselves that are not integrated.”

But another much older declaration comes to mind, from the Book of Job: “Naked came I into the world and naked shall I return.” One level of meaning we may attach to Job’s words is that the infantile vulnerability in which we begin our lives remains, to some degree, within us always until the moment of death, our ultimate vulnerability. The internal infant is a central focus of psychoanalytic therapy. The word “naked” implies exposure and therefore shame. The “parts of ourselves that are not integrated” are indeed split off infantile parts.

I suggest, then, that shame is an earlier, more primitive, affect than guilt. Guilt involves conflict between established internal objects, while shame has its origins in archaic narcissistic states that exist at the very beginning of internalisation. Padel, in exploring Fairbairn’s ideas on the inner and outer worlds, alluded to the infant observations of Donald Gough who noted that the mother’s looking and the infant’s feeding were intimately related. Padel wrote that “mothers who never looked had babies that fed interruptedly; mothers who stared at their babies quickly inhibited their feeding; those babies fed best whose mothers looked now and again. Ever since Gough’s work I have taken the nucleus of the super-ego to be the mother’s eyes” (Padel 1991). Padel is suggesting the infant feels shamefully exposed before the mother’s gaze, which thus becomes persecutory. A complementary interpretation of the same data is that the child does not yet have the psychic structure to contain the narcissistic stimulation of the mother’s gaze, indeed becomes painfully over-stimulated and experiences shame. The total absence of the mother’s gaze is almost equally inhibiting, for the child here is under-stimulated. At either extreme the self-selfobject disjunction may become internalised as self-directed mockery.

Regarding the psychoanalytic treatment of shame, the crucial difference is that while guilt motivates the patient to confess, shame motivates him to conceal (Morrison 1984). Narcissistic patients cannot accept themselves, and cannot believe anyone else could accept them, because of their sense of inner emptiness and their failure to accomplish goals that have, when examined, an archaic perfectionistic quality. Guilt requires forgiveness for its healing, shame asks for acceptance. The therapist’s capacity to accept the archaic mirroring and/or idealising needs of the patient, both within and outside the transference, can provide an important basis for the modification of grandiose ambitions or perfectionistic ideals within the patient, and this will be influenced by the therapist’s experience of his own limitations and where he has come to stand in regard to ambitions and ideals within himself. Moreover the interpretive working through of inevitable selfobject transference frustrations may allow for the gradual development of a more cohesive internal structure. A greater degree of integration means a decreased vulnerability to shame. But this remains for all of us, patients and therapists alike, an incomplete process. Indeed a certain degree of shame-proneness is an essential element in social living. To be told that you “have no shame” is assuredly not to be given a compliment.

I would like to conclude with a brief vignette of a patient whom I will refer to as Ms D. The episode actually occurred before her formal therapy began. She had been through assessment sessions and she and the therapist had agreed that they would commence regular sessions within a few months, when the therapist knew he would have a vacancy. In the meantime they maintained contact by ad hoc sessions, at weekly or fortnightly intervals, where the times were variable. During one session an intense sadness began to well up as she alluded to her extreme deprivation in childhood. She said, “I really have to not talk about this any further. I just can’t deal with it.” The therapist answered, “I guess you have to hold on to it yourself, as you’ve always done, because you don’t yet have a time with me that you can call your own.” Ms D replied, “I’m glad that you understand that, and ashamed that I need you to.”

For our purposes, it is not important to say what brought Ms D to therapy, or what trajectory her treatment eventually followed. Her comment to her therapist was unremarkable, except perhaps in so far as Ms D was unusually articulate, or unusually courageous, in being able to speak clearly of her shame within the transference so early in the relationship. I think it is a safe assumption that most patients entering psychotherapy would have shame feelings similar to those expressed by this woman, even if they did not have her capacity to name them.

It is my experience that the more we understand of the vulnerability to shame within our patients and ourselves, the more we appreciate the need for reliable boundaries within the therapeutic frame. The frame safeguards therapeutic regression, and perhaps it does so by, to some degree, containing the shame that is an inevitable accompaniment to regression. The history of the “therapeutic frame” is another topic worthy of detailed discussion. Freud originally emphasised the requirement that the therapist not gratify the patient’s instinctual cravings, or for that matter countertransference cravings within the therapist. Kohut held that a degree of “optimal frustration” was helpful in the patient developing internal structure and thus having a diminished need for archaic selfobject responses from the environment (Kohut 1971). I am emphasising a different perspective, that the frame is less a matter of frustration than of protection. To give a simple example, the patient who encounters his or her therapist in a public place may experience a painful exposure of those infantile regressive feelings that require a more private setting. That is, the patient can be shamed.

Shame, then, is not an affect restricted to patients within any particular set of diagnostic categories but is, to a greater or lesser extent, an issue for all patients and all therapists. It is an affect the psychotherapeutic process itself may elicit and exacerbate. To some extent, then, to return to the title of this talk, we are always “working with shame in psychotherapy.”

References

Kohut, H. (1971) The Analysis of the Self. International Universities Press, New York. ------- (1972) Thoughts on narcissism and narcissistic rage. Reprinted in The Search

for the Self -- Selected Writings of Heinz Kohut 1950-1978. P. Ornstein, ed.,

International Universities Press, New York, 1978.

Morrison, A.(1984) Shame and the psychology of the self, in Kohut’s Legacy.

P. Stepansky, A. Goldberg, eds., The Analytic Press, Hillsdale, N.J.

-------- (1989) Shame: The Underside of Narcissism. The Analytic Press, Hillsdale, N.J.

Padel, J. (1991) Fairbairn’s thought on the relationship of inner and outer worlds. Free

Associations Vol 2, Part 4 (Number 24) pp.589-615.

Piers, G. & Singer, M. (1953) Shame and Guilt. Norton, New York.

Rosenfeld, H. (1964) On the psychopathology of narcissism. Reprinted in

Psychotic States. Hogarth Press, London, 1965.

Steiner, J. (1982) Perverse relationships between parts of the self. Int. J.

Psychoanal. 63:241-251.

Symington, N. (1993) Narcissism -- A New Theory. Karnac Books, London.