Working With Shame

Gilbert, P., 2003. Working With Shame. Reformulation, Summer, pp.13-15.

The fourth evolutionary origin is the way we have moved from competing via aggression to competing for approval and recognition (Gilbert, 1997). Hence, we want our friends, lovers, bosses and even our patients to like us, value what we do and therefore form positive relationships with us. The drive for positive approval has a major role in shame because it is the feeling of being devalued and becoming an undesirable person with undesirable traits or characteristics that mark shame most closely.

Types of Self-conscious Experience

We can distinguish internal shame as related to feelings of self-devaluation and even self-hatred. External shame relates to feelings/thoughts about what others are thinking. In each case there is a perceived failure to create a desirable, attractive self in one’s symbolic space.

Humiliation is related to social put-down and loss of rank but in this case the person does not feel personally to blame or even personally undesirable. For example, we talk of the humiliation of torture, not of shame. Humiliation is often associated with anger, a sense of unfairness and injustice, and a desire for revenge. The attribution is external, whereas in shame it tends to be internal.

Guilt, which is often confused with shame, is quite different again. This emotion depends upon a recognition of having
done harm. One needs a capacity for empathy and sympathy. This system evolved from the caring system (Gilbert, 1989). Individuals who lack a capacity for empathy and sympathy have trouble with guilt. Thus people with psychopathic disorders can be shame and humiliation prone, but guilt they are not noted for. People can be very caring in their behaviour but this may not relate to empathy. Rather, they are simply trying to create good impressions and entice others to like them. Therapists who try to be “nice” to their patients can do so from an empathic awareness of the need to create safeness and the struggle with shame material, or it can be from more of a (narcissistic need) desire for patients to like them. Supervision can sometimes illuminate these distinctions quite painfully and can themselves be a source of shame when you realise that your behaviour towards a patient was more related to your own needs than theirs.

Early Experience

Early experience sensitises us to feelings of shame and humiliation. In the very first months of life, the positive emotions of the mother are mirrored in her facial and emotional expressions. These have a major impact on the child’s maturing brain. The child’s positive and affectionate systems are being stimulated by the external signals (Trevarthen, & Aitken, 2001). Later the child comes to learn how to stimulate positive emotions by his/her own activity. Imagine a four-year-old little boy drawing a picture. He takes it to his mother who says “wow, what a wonderful picture, you are a clever boy”. In this context he has a positive experience of his mother and a positive experience of himself. The key here is that he has been able to generate positive emotions in his mother due to his behaviour (drawing). This lays down feeling memories, which become the basis for schema of self and others. Suppose the child’s mother says, “oh, these drawings are a real pain, can’t you go and do something else?” Here, he has stimulated negative emotion (eg anger or contempt) in his mother and this will have a reciprocal impact on the emotions in himself. His head may go down with a sense of anxiety and deflation. He is unlikely to be eager to draw much again and if he thinks about drawing there could be an automatic activation of this negative emotional memory – which puts him off the idea. One could understand these in terms of reciprocal roles and/or as I have done in classical conditioning terms (Gilbert, 1992). The key point however is what is laid down are feeling memories of interactions. These are the emotional fuel for shame. One can see that should this be repeated over a period of time then the emotional brain (in the limbic system) will be attuned to picking up cues indicating negative emotion in the mind of others, such as anger, contempt, disgust. As conditioning theory suggests, these feeling memories and emotional systems can be reactivated without any conscious intent but they come with symbolic representations, hence we feel ourselves to be bad, disgusting etc.

Challenge for the Therapist

The challenge for the therapist is thus to work with these self-conscious emotions that have been matured into self-schemas in certain ways. Patients who are very prone to external shame will be highly focused on what the therapist thinks about them. They can infer all kinds of negatives in the mind of their therapist even from quite small cues, such as facial expressions, body postures and so forth. The reason for this is that they are highly sensitive to these cues, possibly as a result of early experience. The patient may become defensive, closed down or angry and the therapist can check what is going through the mind of the patient. It is important to spot these interactions to avoid feeling challenged and then acting out by subtly shaming the patient, turning away from the issue and so forth. For those who work within the cognitive traditions, one would attempt to elicit people’s thoughts and images around interactional scenes, eg one might ask a patient “I noticed a change in your facial expressions, voice tone or the way you just put your hand to your eyes (or whatever) and I wonder what might have been going through your mind at that point?” Predictive empathy, which is depersonalised, can be helpful, “you know sometimes these are such difficult issues that we can feel angry or ashamed if people ask us about them – then we try to defend ourselves. I wonder if that flashed through your mind?” However this is not ‘to put the patient on the spot’ but to open an opportunity for discussion By using ‘we’ rather they ‘you’ you shift the focus. Because shame is so focused on non-verbal behaviour your own voice tones and body language can be key as to how a person responds.

There are a host of ways in which the therapist can work with various beliefs and feelings of external shame. Recall that external shame is the shame related to thoughts/feelings of what others think about the self. For example, the therapist may ascertain specific characteristics that might court shame, such as feelings (eg sexual, anger, anxiety), body appearances, abilities (or lack of them) personality traits, previous experiences, eg abuse. This gives a focus for shame and then an opportunity to elaborate key thoughts, feelings and images around these characteristics. Key dilemmas in shame are whether to reveal or keep hidden, try to accept oneself as is or change (eg lose weight, if shame is about the body) and expose oneself or put up with shame feelings. Many cognitive behaviour therapies argue that therapist guided and supportive exposure can be very helpful. For example socially anxious patients may work in groups to develop their self-confidence via sharing their feelings and worries with others.

Internal Shame

This relates to people’s own/private self, self appraisals and self-critical styles. In our own research we have found there are two key styles (Gilbert et al., in press). In one case a patient adopts a self-critical style because they believe that this will keep them on their toes, help them avoid mistakes and stop them being lazy. A typical slogan here is “if I didn’t criticise myself I would lapse into ineptitude and complacency”. A second type of self-criticism is different and this focuses on the emotion of disgust and the desire, not to improve but to destroy the self or parts of it. Here people want to “get rid of”. These individuals are much more aggressive and sadistic in their self-attacking and can even be self-hating. Generally there is the hope that if they can remove the offending trait or emotion or memory they can survive. If they feel they cannot get rid of these things this ‘loss of control’ can compound their hatred of themselves.

There is now evidence that self-critical people can be quite difficult to help and may not do so well in standard cognitive or other therapies (Rector et al., 2000). One of the reasons for this is that they cling to their self-critical styles because they are highly indoctrinated to do so (eg by parents or peers), feel it is safer to do so, or hope that eventually their self-criticism will direct them to success. Partial reinforcement or self-criticism is also another reason for it being difficult to extinguish.

We have found yet another reason, which is that self-critical people are often focused on threat and find it difficult to feel safe or connect with empathic feelings. Even when they are challenging their self-criticisms, the emotion of their reevaluations can be cold or indeed hostile (come on - look at the good things you have done – why do you always focus on the negative!). Or sometimes people think they can use cognitive techniques as another form of control. For example a competitive and autocratic man thought I was going to teach him how to control his emotions (even better than he now tried to do!).

It is important to check this with people and to discuss with them the need to try a different emotional tone to their reevaluations. For example, supposing a mother says “I am a bad mother because I sometimes get angry with my children. I don’t always do with them the things I could do and I am not always filled with motherly love”. She could generate a number of alternatives by looking at the things she does do and so forth. However, we suggest that she could learn to be more compassionate and understanding by focusing on what this would mean. A compassionate response would involve both an emotional feeling of empathy for the struggle of looking after children at times and a focus (shift of attention) to more positive things in the relationship.

Compassion Training

Compassionate acceptance therefore requires people to not simply challenge their beliefs or focus on the idea that they have cognitive distortions or cognitive errors (shaming terms that I rarely use now) but to acknowledge why they feel and think as they do. In compassionate work we might help somebody to focus on an image of compassion and practise “feeling” that image that is generating that feeling. This is no different from helping people relax if they are working with their anxiety. We are trying to generate a different affective experience. There is much to compassionate development that includes attentional retraining, imagery, generating affect, changing behaviour and so forth.

What we have found in our work is that patients with long-term difficulties find this very difficult to do. They may say they can be compassionate to others, and sometimes this is true, but often what they mean by this is that they know how to be nice. It is very unclear how much empathic feeling goes along with that. One patient found it almost impossible to generate compassionate imagery. In a study we have just completed with students we found that self-critics could easily generate images of a critical part of themselves; they could “see” the fact and emotional tone and once created these images could stick with them. However, they found it difficult to create such vividness in generating a compassionate image and felt that the images easily dissolved. Keeping attention to “I” was very difficult. Individuals who were low self-critics tended to be the opposite. We suspect therefore that the inability to generate compassionate and reassuring self-images are partly the difficulty with some of our patients. One patient, on reflecting on compassionate mind work, thought that “I never realised how cold and hostile my thoughts were to myself and about myself and for how many years I had lived in that place. Beginning to feel compassionate for myself shows me that other places are possible”.

One of the key ingredients to a cognitive behavioural approach is what we might call the “physiotherapy” element, where people have to train themselves to develop aspects of themselves that are undeveloped or turned off. This is become increasingly a focus for people who are looking at psychotherapy from a neuroscience point of view (Schwartz & Begely, 2002). Therapy becomes a process of activating and exercising different brain pathways via attentional refocusing, reattribution of meaning, behavioural change and practice. Through practice one begins to develop new links in the brain. Meditation can be part of this too. This approach is not everybody’s cup of tea but personally I like it. It helps me think through the kinds of experiences people might need to develop and work on inner abilities. It is a way of thinking about how our exposure can help people. In time, developing compassion in the same way that one might develop other affective experiences may prove to be a powerful antidote to shaming and attacking both self and others.

References

Gilbert, P. (1989). Human Nature and Suffering. Hove: Lawrence Erlbaum Associates Ltd.
Gilbert, P. (1997) The evolution of social attractiveness and its role in shame, humiliation, guilt and therapy. British Journal of Medical Psychology, 70, 113-147.
Gilbert, P. (1998). What is shame? Some core issues and controversies. In, P. Gilbert & B. Andrews (eds.). Shame: Interpersonal Behavior, Psychopathology and Culture (pp. 3-38): New York: Oxford University Press.
Gilbert, P. (2000) Social Mentalities: Internal ‘Social’ Conflicts and The Role of Inner Warmth and Compassion in Cognitive Therapy. In, P. Gilbert & Bailey K.G (eds.) Genes on the Couch: Explorations in Evolutionary Psychotherapy (p.118-150). Hove: Psychology Press.
Gilbert, P. (2002) Body Shame: a biopsychosocial conceptualisation and overview, with treatment implications. In, P. Gilbert & J. Miles (eds). Body Shame: Conceptualisation, Research & Treatment. (p. 3 – 54). London. Brunner-Routledge.
Gilbert, P. & Clarke, M., Kempel, S. & Miles, J.N.V. (in press) Forms and functions of self-criticisms and self-attacking: An exploration of differences in female students. British Journal of Clinical Psychology.
Rector, N.A., Bagby, R.M., Segal, Z.V., Joffe, R.T & Levitt, A. (2000). Self-criticism and dependency in depressed patients treated with cognitive therapy or pharmacotherapy. Cognitive Therapy & Research, 24, 571-584.
Schwartz, J. M & Begely, S (2002). The Mind and the Brain: Neuroplasticity and the Power of Mental Force. New York: Regan Books.
Sedikides, C & Skowronski, J.J. (1997). The symbolic self in evolutionary context, Personality and Social Psychology Review, 1, 80-102.
Tangney, J.P. & Fischer, K.W. (1995, eds). Self-Conscious Emotions: The Psychology of Shame, Guilt, Embarrassment and Pride. New York: Guilford.
Trevarthen, C & Aitken K (2001). Infant intersubjectivity: Research, theory, and clinical applications. Journal of Child Psychology and Psychiatry, 42, 3-48
Triandis, H.C (1989) The self and social behavior in differing cultural contexts. Psychological Review, 96, 3 506-520

Full Reference

Gilbert, P., 2003. Working With Shame. Reformulation, Summer, pp.13-15.

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