Martin J Dorahy

Department of Psychology

University of Canterbury

New Zealand “I did not fear punishment, but I

dreaded shame. I felt no dread but

that of being detected” (J. J. Rousseau, 1782 )

Shame “In the gaps and clumsy steps in human intercourse, in the

misunderstandings, the misperceptions, and misjudgements, in the blank

mocking eyes where empathy should be, in the look of disgust where a

smile was anticipated, in the loneliness and disappointment of

inarticulate desire that cannot be communicated because the words

cannot be found, in the terrible hopeless absence when human

connection fails, and in the empty yet rage-filled desolation of abuse-

there in these holes and missing bits lies shame. Shame is where we fail.

And the most fundamental failure is the failure to connect with other

human beings—originally the mother” (Mollon, 2006, p. xi).

Primary and secondary Emotions

Primary emotions Secondary (self conscious) emotions

Very early (0-9 m),

require no SC

Present later (18-24 m), require SC

Joy

Distress

Anger

Fear

Disgust

Surprise

Shame

Guilt

Pride

Embarrassment

Lewis, 1992; Tracy & Robins, 2007

Self-awareness; self-rep.

Emerge later

Facilitate social goals

No universal facial expressions

More cog. complex

Shame (affect)

Motive

Restore positive self-view

Protect Injured self-view (from further harm)

Competence restoring positive self view

high

Low

Approach/repair/repeat (behaviour)

Avoid/withdraw/hide (behaviour)

De Hooge et al, 2010

Adaptive aspects Efforts to avoid shame activation can:

Increase pro-social behaviour (e.g., Scheff, 1997)

Reduce damage to social status (e.g., Gilbert, 1998)

Effects of shame on the person Shame

influences vulnerability to mental health problems

Affects expression of symptoms,

Affects abilities to reveal painful information,

Associated with various forms of avoidance (e.g., dissociation and denial)

Creates problems in help seeking • (Gilbert & Procter, 2006, p. 353; Hook & Andrews, 2005)

“Shame operates everywhere in therapy cause clients are constantly concerned

about what part of their inner experience can be revealed and what parts must be

hidden”

Greenberg & Paivio, 1997, p. 235

Why focus on shame in therapy “Overwhelming feelings of shame may contribute to

early treatment drop-out or indeed may be the reason why some individuals never present for treatment in spite of suffering from debilitating symptoms…” (Lee et al., 2001, p. 464)

Has implications for all stages of treatment (Herman, 2011), including the therapeutic alliance

Risks for therapy in overlooking shame

Shame impedes social connection (‘severs interpersonal connection’ – Kluft, 2007), and therefore impedes the soothing and emotional regulation that comes from others (Hahn, 2009). Thus, the presence of shame will strongly influence the degree to which the therapeutic relationship can be seen as safe and be utilized to bring about progress.

Impact of shame therapeutically Shame will undermine exposure work/trauma

processing (e.g., narrative work, CBT, EMDR, rescripting) (Blum, 2008, Kluft, 2007; Lee et al., 2001).

Will have likely implications for relapse if not addressed

Why focus on shame and guilt in trauma? (cont.) Is linked to more overt symptomatology such as

depression, PTSD avoidance, dissociation, stigmatisation

Shame defined “Shame can be defined simply as the feeling we have

when we evaluate our actions, feelings, or behavior, and conclude that we have done wrong. It encompasses the whole of ourselves; it generates a wish to hide, to disappear or even to die” (Lewis, 1992, p. 2)

Shame is the affect of inferiority (Kaufman, 1989)

SHAME IS RELATED TO THE SELF

Repair behaviours designed to repair self-view

What is shame? “A complex and disorganizing experience dominated

by painful emotions, obsessive rumination, and condemning imagery. Feelings of inadequacy and worthlessness are accompanied by tormenting and accusatory thoughts and an excruciating sense of aloneness” (Hahn, 2009, p. 303)

Shame and relationships Shame is inextricably linked to emotional

relationships.

Emotionally significant relationships play a central role in the etiology, development, and expression of shame

Hahn, 2009

4 shame phases: Nathanson (1992) Four phases of shame:

Trigger

Physiological/affective reactions

Cognitive reactions

Behavioural/defensive responses

Causes of shame - triggers Shame is a pan-human defensive emotion evoked by

two different types of relational events:

1. The recognition of one’s own inferior status and resultant aversive feelings.

2. The recognition of the self ’s failure to conform to social norms and expectations.

Fessler, 2007; see also Budden, 2009

Shame - affect Shame is typically a blend of other (basic) emotions

like anger, anxiety and disgust (Gilbert, 1998, 2010)

Shame & attributions (cognitive)

Shame

Tracy & Robins, 2008

Internal Stable Uncontrollable Global

Shame – behavioural responses Compass of shame

(Nathanson, 1992)

Attack self

Avoid Withdraw

Attack other

One typology of shame External shame: thoughts and feelings about how

one is believed to exist in the minds of others

Internal shame: self-directed evaluations, thoughts and feelings about inadequacies and flaws.

Trauma and shame (cont.) People feel ashamed for:

1) what happened

2) how they (e.g., their body) responded

3) who they are

Boon, Steele, & Van der Hart, 2011; Dorahy & Clearwater, 2012, Herman, 2011; Talbot, 1996

Shame

Embarrassment

guilt

Hi self crit.

Relational trauma/victimisation

narcissism

Anger/disgust directed

at self

Other’s appraisals of self

Dep, low SE

Suicide

humiliation

Exposure + neg action

Exposure + pos action

Incompetence Inferiority Defective

Exposure but self not to blame

Violation of values

Defense against shame

Empathy absent

Empathy present

Differentiating guilt and shame

S

h

ame

Gu

i

l

t

Emotion of social sanction Emotion of internal sanction

Related to entire self Related to specific behaviour

Concerned with ideals Concerned with prohibitions

Self-oriented Other/communal-oriented

Teroni & Deonna, 2008

Differentiating guilt and shame

Shame

Gui l t

Fear of intimacy

No intimacy fear

Behavioural and characterolog. self-blame

No blame of others

Blame of others

Self-derogation

Lutwak, Panish, & Ferrari, 2003

Shame: Behavioural markers and actions

Shame

Blushing

Diverting eye Gaze/breaking eye

contact

Hunching of Shoulder/shrinking/compression

of body

Dropping of the head/ turning away

concealment

No/reduced self relev.

Momentary Blank mind/inability to speak

Movement from others

Shame, Schizophrenia and EE (Wasserman et al., 2012) EE evidence by criticism/hostility or emotional

overinvolvement.

Predicts relapse and poor prognosis in schizophrenia (Weardon et al., 2000)

Does shame for having a family with schizophrenia increase criticism and hostility toward that person?

Does guilt/self blame lead to more emotional overinvolvement (as an overcompensatory repair strategy?

68 family members of patients with schizophrenia or schizoaffective disorder

Wasserman, Weismna de Mamani & Suro, 2012

Tools SCID-I diagnosis of patient; family member given:

Five Minute Speech Sample (Magana et al., 1986) to assess EE

Shame and Guilt/self blame Qs for Self-directed Emotions for Schizophrenia Scale

“Having a relative with schizophrenia is a great source of shame”

“Having a relative with schizophrenia is something for which I feel blameworthy”

1 (not at all) - 7 (very true)

Do Shame, guilt predict high EE?

Shame and guilt predict high EE

But shame does not predict hostility/criticism uniquely

And Guilt/self blame does not predict emotional overinvolvement uniquely

Shame

Guilt/Self blame

High EE

EOI

Criticism/Host.

Exp (B) =1.55

Exp (B) = 2.09

Shame, social anxiety, psychosis Shame of having the diagnosis may heighten in

schizophrenia due to stigmatisation (social rejection) or social threat

This may be partly associated with high social anxiety evident in schizophrenia (+30%)

Therefore:

Hieghtened anxiety after first episode of schizophrenia as stigmatisation/social threat increased

Heightened shame in those who feel more stigmatised by diagnosis.

Birchwood et al., 2006

Shame, psychosis and social anxiety

79 individuals assessed 6 months after first episode psychosis (mean age 23; 61 males, 18 females). 52 schizophrenia.

23 social anxiety vs 56 no SA

Shame measures

Personal Beliefs about Illness Q (Birchwood et al., 1993) – shame subscale (appraising psychosis as shameful)

Others as Shamer Scale (Goss et al., 1994) – perceiving as shaming because of diagnosis

Shame, psychosis and social anxiety Measures Social anxiety No social anxiety

PBIQ Shame 16.5 (3.2) 12.9 (2.5)

OAS 38.3 (14.9) 18.1 (13.4)

• Social anxiety group higher shame • Having diagnosis is shameful • Others will shame as a result of having diagnosis

• Unfortunately no correlations provided by shame and psychotic symptoms (i.e., is shame associated with having psychotic symptoms).

• They would argue this relationship mediated through beliefs

about being social threatened/ostracized, rather than direct link between psychosis and shame

Shame & Psychosis: Discussion Shame in family members regarding a person

schizophrenia increase EE environment

Shame heightened in psychosis, especially those with increased social anxiety (stigmatisation/fear of social rejection)

Shame & DID: Starting point Shame discussed increasingly in complex trauma and

DID literatures (e.g., Chu, 2011; Dorahy, 2010; Dorahy et al., 2013; Dyer et al., 2009; Kluft, 2007

Yet, very little work has empirically examined shame in dissociative disorders.

Is shame elevated in DID compared to psychiatric comparison groups?

Is there an association between shame and dissociation (e.g., Talbot et al., 2004)

Shame & DID: Method N = 66 psychiatric patients

DID: n = 35; M= 2; age = 44.88 (sd=10.45)

Vs

Non-DID (e.g., DDNOS [3], PTSD [10], complex dep/anxiety[16],

BPAD[2]): n = 31; M=7; age = 39.51 (sd=9.73)

Sig for age [F(1,64) = 4.62, p<.05]

All had child abuse and/or neglect

Shame & DID: Scales Completed:

Multidimensional Relationship Questionnaire (MRQ; Snell et al., 1996): Rel preoccupation, Rel. anxiety, Rel. Dep. Fear of rels.; Rel. esteem, motivation, satisfaction.

Personal Feelings Questionnaire-2 (PFQ-2; Harder & Lewis, 1987)

The Compass of Shame Scale (CoSS; Elison et al., 2006)

Avoidance, withdrawal, attack self, attack other

The State Shame and Guilt Scale (SSGS; Marschall et al., 1994)

Stress Reactions Checklist for Disorders of Extreme Stress (SRC; Ford et al., 2007)

The Childhood Trauma Questionnaire (CTQ; Bernstein & Fink, 1998)

Dissociative Disorders Interview Schedule: BPD, DID (DDIS; Ross et al., 1989).

Dissociative Experiences Scale (Carlson & Putnam, 1993

Shame& DID Results: Difference Variable DID Non-DID F p

Abuse-Negl 86.35 (22.9) 64.13 (23.7) 19.01 .000

DESNOS 32.51 (10.4) 22.67 (9.4) 16.12 .000

DES-tot. 55.14 (18.6) 22.03 (14.1) 63.77 .000

DES-Tax. 53.14 (27.5) 14.83 (15.0) 69.24 .000

PFQ-Shame 25.71 (6.6) 19.42 (6.7) 14.95 .000

PFQ-Guilt 15.54 (4.9) 13.41 (3.7) 3.81 .055

CoSS Avoid 32.00 (6.7) 33.7 (6.8) 1.06 .131

CoSS Attself. 48.63 (9.6) 45.9 (10.4) 1.23 .27

CoSS Withd. 49.66 (6.3) 45.7 (8.4) 4.65 .035

CoSS AttOth. 23.08 (8.4) 27.29 (8.6) 3.89 .053

Rel. Preocc. 1.68 (2.7) 1.96 (4.1) .15 .70

Rel. Anx 15.25 (6.2) 10.71 (7.4) 7.47 .008

Rel. Dep 13.71 (5.8) 8.35 (6.3) 13.03 .001

Fear of Rel 14.57 (5.2) 11.4 (5.5) .6.14 .016

Study 2 Results: Correlations DES-T Shame

DES-T

Shame .61 (.000)

Guilt .55 (.000) .59 (.000)

DESNOS .67 (.000) .70 (.000)

CoSSAvoid -.24 (.06) -.17 (.18)

CoSSAttSelf .32 (.01) .66 (.000)

CoSSWithd .54 (.000) .69 (.000)

CoSSAttOther -.18 (.15) -.04 (.48)

Rel.Preocc -.02 (.89) -.16 (.63)

Rel. Anxiety .47 (.000) .52 (.000)

Rel. Depression .46 (.000) .41 (.001)

Fear of Relationships .34 (.006) .38 (.002)

Does dissociation or shame predict relationship problems?

hierarchical regression (except on Rel preoc-no Correl)

Predictors: Shame (step 1); DES-T (step 1); Shame × DES-T (Step 2)

What predicts rel. difficulties?

Relationship Anxiety: RsqAdj = 28.6%, F(3,61)=9.58, p<.05

Relationship Depression: RsqAdj=20.1%, F(3,61)=6.36, p<.05

Fear of Relationships: RsqAdj=11.8%, F(3,61)=3.85, p<.05.

Shame

DES-T

Shame by DES-T

Rel. Anxiety

Rel. Depression

Fear of Rels.

UniqR2=8%, p <.05

UniqR2=3%, p =.07

UniqR2=7%, p <.05

UniqR2=4%, p =.07

Discussion DID higher on dissociation and shame than tight non-DID

comparison

Also higher on relationship anxiety, depression and fear of relationships

Dissociation and shame related to: shame, withdrawal and attack-self (thus dissociation

association with more awareness of shame)

Relationship anxiety and depression, & fear of rels.

Both shame and dissociation uniquely predict different aspects relationship difficulties Both predict rel. anxiety (dissoc-trend).

Dissoc predicts rel depression

Shame predicts fear of relationships (trend)

Shame, psychosis & dissociation: the future Both schizophrenia and DID relational disorder

Etiology:

DID, ?Schizophrenia

Content and nature:

DID

Other ‘selves’, ‘personified’ object relations (internal)

How other people relate to person (external)

Schizophrenia

Auditory verbal hallucinations, ego-dystonic objects relations (internal)

How other people relate to person (external)

All these areas ripe for investigation of shame, especially comparative work

Therapy as shaming “Because of the power imbalance between patient and

therapist, and because the patient exposes her most intimate thoughts and feelings without reciprocity, the individual therapy relationship is to some degree inherently shaming” (Herman, 2011, p. 271).

Why is shame so hard to access in clients? Risks in telling shame narratives for client:

Being perceived as inferior (thus reinforcing shame). Feeling they may be perceived as even less than they were before narrative.

Evoking disgust in the other and therefore repelling them.

The connection, even if tentative and weak with therapist will be broken.

Having importance of this feeling dismissed, overlooked and ignored

Pacing shame in therapy “In the same way that narratives of fear must be

titrated so that the client experiences mastery over fear rather than a reinstatement of it, so too narratives of shame should be titrated so that the client experiences dignity rather than humiliation in the telling” (Cloitre, Cohen, & Koenen, 2006, p. 290)

Roadblocks - therapeutic relationship “Transformation of shame is highly dependent on

the therapeutic relationship” (Greenberg & Paivio, 1997, p. 235)

The quality of therapeutic relationship is highly dependent upon the client AND the therapist

“Shame triggered in either therapist or patient can be a source of therapeutic rapture” (Gilbert & Procter,

2006, p. 353)

Roadblocks: the therapists What is one of the biggest impediments to the

clients overcoming shame?

The therapist!!!!

Shame in psychotherapy “Despite its destructive toll, shame seldom is

addressed in psychotherapy. Patients almost never disclose shame as a presenting complaint, and psychotherapists often do not address shame due to difficulties sifting through countertransference issues unique to shame (Hahn, 2000) and their own painful encounters with shame in childhood and psychotherapy supervision (Hahn, 2001)”

Hahn, 2009, p. 303