Saturday, May 23, 2015




It is constantly becoming clearer that all ­models of mental health intervention and support must explore the patient’s feelings of disgust/shame early in therapy.  Symptom reduction, while important, can mask the desperate need to feel less ashamed.  Because shame, as opposed to disgust, develops in a verbalized, non-body-based system it runs around in your patients mind in thoughts and words.  It is embarrassing to talk about embarrassing things.  Colluding with your patient to not investigate early patterns of feeling inadequate or flawed allows them to go on thinking there is something wrong deep inside them.

If you don’t have a practiced model for identifying these dynamics, there will be more and more questions about the long-term efficacy of your work.  Symptom reduction, with documented results from Evidence Based approaches, have gained deserving validation.  They are becoming the expectation. Neuroscience will also soon be pressuring us to document recordable development in our patient’s abilities to recognize, tolerate and soothe feelings of disgust and shame.

Psychoanalytically informed work is rapidly moving in the direction of sensitivity to patient’s primary affects.  There is an evolving body of neuroscience data proving primary affects of shame and disgust underpin many later developing distressing self-states.  This affective neuroscience data is confirming long-held understandings in Attachment Theory and Family Systems.  The neural pathways that are later associated with feelings of shame begin to take recognizable form early in life.  Shame will be discussed in the early chapters of my writing because it is observable and mutable in adults and youth through talking.  Shame illumination is useful to clients in many therapeutic milieus; further clarification will be done in Chapter 3.

Disgust and shame emerge in two different and overlapping pathways.  Krystal "proposed that all later-developing affects evolve out of a neonatal state of contentment and a state of distress that differentiate into two developmental lines, an infantile nonverbal affect system and an adult verbalized, desomatised system" .  (Krystal, H. 1988 What cannot be remembered or forgotten., p. 219 New York: Psychology Press).  Two of the states of distress mentioned above are disgust and shame.  Shame is a neonatal affective state of distress which is cognitive and not based predominantly in bodily sensations.  Blushing systems, emerging in infants at 10-12 months, include the same circuitry  evident when an adult tells us they are feeling embarrassment or shame.

The nonverbal affect state of disgust includes touch and smell and is not as interconnected to verbal development. Disgust needs to be explored in the latest stages of therapy the patient can tolerate exploring concepts such as Jung’s “Shadow” and not feel ashamed for harboring its dark influences.  Within sublimated shame, disgust can be useful for becoming aware of the patient’s “Healthy Grandiosity”.  A solid footing of soothing shame feelings is necessary prior to the exploration of  "Shadow" and disgust.  Therapeutic sensitivity to utilizing disgust will be explain in later chapters of this manual. 

The “adult verbalized, desomatised system” mentioned above is included in later (socialized) developing shame states.  Shame grows along with language based cognitions.  Our talk therapy approaches can give us access to these volatile primitive organizations. Feelings of inadequacy, being flawed, inferior or ashamed can, and should, be illuminated early in therapy.  Many groundbreaking analysts have professed this same belief about the requirement of exploring shame.  Sandor Ferenczi stated this very firmly: “Analysis must make possible for the patient, morally and physically, the utmost regression, without shame.”  (Dupont, J. 1995  The Clinical Diary of Sandor Ferenczi), entry dated June  1932 . To have dissolved shame in the heat of observation allows the courage to feel the dread of annihilation. 

"Shame, or blushing, is evident in infants at 10-12 months old.  The neural-circuitry we utilize for blush develops with the occipital cortex, which is the seat of our language development".(Feldman, Greenbaum, & Yirmiya, 1999, p. 223)  These early embarrassment pathways emerge out of the patient’s earlier attachment processes. “Face-to-face interactions, emerging at approximately two months of age, are highly arousing, affect-laden, short interpersonal events that expose infants to high levels of cognitive and social information.  To regulate the high positive arousal, mothers and infants…..synchronize the intensity of their affective behavior within lags of split seconds.”  (Schore, A., 2012, The Science of the Art of Psychotherapy, p.231).  Discussing early childhood feelings of embarrassment or shame allows the analyst and patient to synchronize the intensity of their affective behavior within lags of split seconds.  The process of two brains resonating in low and high arousal states allows a new strategy for modulating these states with each holding the other in mind.

For 20 years I have used a model of illuminating my patient’s childhood patterns of feeling shame to inform my work with their distress from symptoms of anxiety, depression and/or undue concern with the thoughts and feelings of others.  Although my process with these hundreds of people is not at all formulaic, it is amazingly similar with patients across the board, from six to 80 years old. We need to be near the client in utter regression for them to know they can experience their worst feelings about themselves, at the same moment as having a feeling of belonging with another human-being.

Several quotes will follow from (Morrison. A., 1995, SHAME, The Underside of Narcissism, New York: Norton Press). In this book Morrison did a review of the existing literature about a type of guilt which is about the subject’s internal feelings about themselves.  He differentiates this from research about feelings of guilt about specific behaviors.   As I read this book on a weekend in 1995 imagined helping my 11:00 AM Tuesday patient exploring his early feelings of embarrassment.  I felt confident he would understand Morrison’s ideas and benefit from clarification of his life-long feeling of not being good enough. He was well educated and had worked hard in therapy for two years.  To my surprise halfway through my 9:00 AM Monday patient I realized he would easily understand and benefit from these ideas. He had a vocational high school education and worked at a plywood mill.  The value of these two explorations seemed obvious; however it was their reports of the utility of their new awareness presented in their next weekly session which solidified my new sensitivity. 

In general you want to start the process of Shame illumination during the Psych/Social questioning, after therapeutic rapport is established.  I ask the patient to tell me about the earliest memory of shame and/or embarrassment they have.  The Shame question usually happens during the third, fourth or fifth session.  At the end of the session of their disclosure I ask the patient to notice during the week if they feel any of that embarrassment.  Any type of distressing affect the patient experiences is likely to contain some similarity to how they coped in childhood. If it isn’t an obvious match to current life feelings of distress we look for some other, more representative memory of shame.  My patient and I then refer to this memory throughout the therapy process. “I am convinced of the central importance and significance of shame as an affective experience- for each of us, as for our patients.” (p180)  Being able to cope with our imagined flawed-ness in areas our early caregivers had deficits, is part of the glue that holds our self-narrative together. The view of us as inadequate is a central organizing principle of our narcissism. “The authors cited demonstrate, I believe, that shame earns its place at the center of narcissistic experience.” (p62)

The neurological substrata of later developed shame structures can be detected in the first few months of life.  Looking from the direction of adult structures which create distress for the patient, it is relatively easy to hypothesize earlier coping strategies which may have generated unhealthy habits in development.  It is difficult to guess what adult defensive patterns are going to become rigidified into what type of distress by looking at an infant.   Winnicott want us to know about the patterns we were seeing in infants which are easier diagnosed in adult stages of life. “In seeking the etiology of the False Self we are examining the stage of their first object-relationships. At this stage the infant is most of the time unintegrated, never fully integrated; cohesion of the various sensori-motor elements belongs to the fact that the mother holds the infant, sometimes physically, and all the time figuratively.  Periodically the infant’s gesture gives expression to a spontaneous impulse; the source of the gesture is the True Self,…….We need to examine the way the mother meets this infantile omnipotence revealed in a gesture (or a sensori-motor grouping).  I have here linked the idea of the True Self with the spontaneous gesture.  Fusion of the motility and erotic elements is in the process of becoming a fact at this point of development of the individual.” (Winnicott, 1960, Ego Distortions in Terms of True and Falsae Self).  False Self holds off use of spontaneous gestures because of the futility of their use.

When the mother “repeatedly fails to meet the infant’s gesture; instead substitutes her own gesture which is to be given sense by the compliance of the infant.  This compliance is the earliest stage of the False Self, and belongs to the mother’s inability to sense her infant’s needs.” (Winnicott, 1960)

As therapists we are modelling the necessary “client-lead-therapist-follows” view of their life, to allow low energy reorganization of the patient’s reflected sense of self.  Childhood shame will carry a feeling of being unseen, or un-seeable. When we remember this episode in the following weeks, the patient feels carried-in-mind. They now feel seen in a moment in their history of feeling unseen in the world.  A matrix of attachment processes are active in feeling the self being carried-in-mind.  The areas of attachment related to the neocortex are highly useful for inhibiting impulses from the brain stem and above.  To imagine telling a therapist how you acted when you feel angry or afraid, will provide a different set of options for a patient.

Parents, who as children survived threats to their survival, such as abuse or neglect, developed coping-strategies to tolerate their caregiver's behaviors.  In the most extreme these habits develop into personality constructs and persist into adulthood. Healthy friends in childhood don't like being around people who use defensive coping-strategies, so the healthier abused or neglected children begin to soften up these patterns.  In the stress of experiencing repeated high threatening situations, these individuals may find their less complex, more primal strategies for survival more useful because of the speed and clarity knowing how to act. Those reactions are processed in the primitive brain/body in rapid, low energy organizations that can dominate later developing levels. The patient may have little awareness of the similarities between his/ her action patterns in high stress environments and the pattern they used for navigating in his/her family of origin.

When the mother “repeatedly fails to meet the infant’s gesture; instead substitutes her own gesture which is to be given sense by the compliance of the infant.  This compliance is the earliest stage of the False Self, and belongs to the mother’s inability to sense her infant’s needs.” (Winnicott, 1960)

Much to my delight I found a couple of my heroes in thinking about PTSD treatment had already written about the importance of exploring shame with our patients.  Judith Herman in her 2007 paper Shattered Shame States and their Repair (p. 7), presented at The John Bowlby Memorial Lecture stated: “Separations, which evoke fear and protest in normal toddlers, do not evoke shame; rather, shame can be seen in reunion interactions, when the toddler’s excitement is met with indifference or disapproval.  To a certain extent, such experiences are inevitable and normal, since no caregiver can be empathically attuned to her child at all times, and sometimes the caregiver must chastise the child.”   She concludes her paper with two ideas I am professing here “future research is needed to develop a fuller understanding of the neurophysiology of shame,……and to explore the potentially therapeutic effects of addressing shame as a central issue in the treatment of trauma survivors.”

At the core of our disposition are our primary affect states. These primitive states have patterned themselves into our later forming dispositions with ever increasing complexities and many overlapping influences as we developed as humans.  Disposition is most changeable (volatile) in the latest developing cognitive realm.  Shame is the simplest of the primitive affect states to identify and the most searing.  The components organized inside us around ideas that we are inadequate, flawed or bad can be desublimated out to further purify the sovereignty our innermost self.  The behaviors that result from accurate sensing of our dispositions become the bedrock of our Authentic Self.

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