The Treatment of Shame in a Dual Diagnosis Treatment Center Setting

Written By: Dr. Seth C. Kadish Date: April 9th, 2009. Topic: Dual Diagnosis.

Shame is a critical issue to the client (behaviorally, emotionally, spiritually, cognitively, and physically) and therapist. The purposes of this article are to discuss and educate about the nature of shame and approaches to allevating shame in a clinical setting.

An operational definition of shame

According to Merriam-Webster, shame is “a painful emotion caused by consciousness of guilt, shortcoming, or impropriety; a condition of humiliating disgrace or disrepute.”
This definition mirrors the vast research on the topic, viewing shame as either an emotion, a state of mind, or both.

Pattison (2000) emphasizes the cognitive aspects of shame, in the following description:

A distinctive set of features that helps to distinguish shame from other experiences revolves around the perception of the self as being judged to be inferior, defective, incompetent, undesirable, or unlovable . . . Shame experience is often described as inducing a sense of inferiority, valuelessness, or personal diminishment through failing to meet one’s own adopted standards and ideals (p. 76).

Bradshaw (1988) describes shame as “an excruciatingly internal experience of unexpected exposure.” This definition helps us distinguish shame from embarrassment. While the latter has everything to do with exposure (being seen by others in a negative light), and is generally accompanied by blushing, aversion of the eyes, and other physiological reactions, the former is an inner state of being, a series of self-judgments, negative self-talk, linked to a core belief (schema) of worthlessness, and concomitant maladaptive assumptions and automatic thoughts.

From a clinical perspective, this schema of shame is the source of numerous negative patterns of thought, emotion, and behavior, including poor self-esteem, self-sabotage, and over-apologizing. Shame is a state of mind that may not be easily identified by the client, but will manifest in behavioral or physical form. The client only knows, “I’m no good,” “I’ve always been bad,” “I’m not worth saving,” “I can’t be helped.” Such statements are sure-fire indications of a state of shame.

By way of example, my client, Ronnie, a businesswoman in her mid-40s with a history of sexual trauma and poor interpersonal boundaries, stated upset at friends who had overstayed their welcome in her home.

“I was very angry at them.”
“Did you tell them to go?”
“Not really.”
“Eventually they left.”
“They did, and I was angry at them and…” (a pause)
“Yourself?”
(a nod) “Myself, too.”

Exploring her thoughts and behaviors, I arrived at the conclusion that this negative pattern of caretaking rested on a foundation of worthlessness. Ronnie felt that she had no rights and/or that her rights were secondary to the desires of others. She was able to recognize her rage, but lacked awareness of the shame underlying and fueling the anger.
Ronnie, like many clients, was able to connect with a readily accessible emotion (anger), but unable to see its connection to shame.

How can shame be diminished?

Shame can be lessened through revelation. The shame-based client hides. He fears exposure. His negative patterns of thought, emotion and behavior are designed to disguise his deep feelings of shame, which must be brought into the light.

Shame can also be lessened through alteration, which connotes a shift in self-perception. To build a client’s self-esteem, the clinician must help alter the client’s negative self-image. This can be done by addressing specific patterns of behavior – manifestations of the deep, core shame – or by tackling the shame directly.

Attacking shame-related patterns: an oblique approach

Using an oblique approach, the clinician would first note the negative patterns of thought, emotion and behavior through individual counseling and/or observation of the client in a group or milieu setting. Patterns are revealed through speech, mannerism, and inter- personal interaction, as well as writings, drawings, dreams, and other expressions of the self.

Let’s look at Scott, a middle-aged client with an easygoing manner, who demonstrates people-pleasing behavior in a dual diagnosis treatment center setting. He is always the first to group, has words of encouragement for his peers, and confesses that while he thinks highly of others, he does not think so well of himself. When questioned further, Scott gives a nervous smile, and tentatively states, “I never feel like I mean very much, you know?”

Rather than dealing with the shame directly, the clinician can address the people-pleasing behavior and its unstated message: “I will be pleasant and prizing to you so that you won’t attack me, revealing my hidden, horrible self to the world.”

This can be done using any number of modalities, e.g., brief psychodynamic, objection relations, cognitive-behavioral, etc. One could, for instance, utilize REBT techniques to look at the behaviors and consequences around a specific shameful incident, and dispute the client’s irrational thoughts surrounding that incident. A brief psychodynamic psychotherapy approach in a 30-90 day, residential treatment center setting could also be fruitful.

In a similar vein, the Pointing Out Patterns® approach (Kadish, 2008) would help the client to recognize his people-pleasing thoughts and behaviors, and diminish these by having him refrain from “cheerleading” while simultaneously being more truthful with others. Treatment center staff would, in turn, increase positive behaviors through verbal reinforcement, e.g., “Good job, Scott.”

Attacking shame-related patterns: a direct approach

To redeem oneself – to once again deem ourselves important and worthwhile – is a liberating experience. We were not born “less than,” but instead developed a negative self-image in response to particular life events, coupled with the influential words and actions of authority figures. It is the clinician’s task in working with the shame-based client to help him reclaim his birthright of wholeness and completeness.

To cite a popular example, in the movie, “Rocky,” the title character redeems himself by going all the way in the title fight. Rocky’s battle with Apollo Creed is a powerful personal metaphor for fighting back in life. He does not have to win to feel worthwhile, but must fight with all his strength and heart, proving to himself that he is a man of substance and character, and not a loser. The shame-based client can redeem himself, too, with the assistance of the clinician, who takes a direct and straightforward approach to the client’s shame.

Having the client stand in front of a group of peers and share an intimate thought or feeling, or even stand quietly and merely allow others to look at him, is a simple and powerful technique to break shame. The client will want to defend against feelings of exposure and vulnerability. Standing and holding will surface these feelings, and allow a working-through. (Note that this should only be done with the client’s cooperation, otherwise the client may feel shamed into doing it. This would be contradictory to the purpose of the exercise.)

The clinician, working with the client’s resistance, may also pull the client into a spontaneous public performance, e.g., singing, dancing, clowning that will further diminish feelings of shame and anxiety at being looked at and judged. The client might be encouraged to diminish shame by acting silly in a public setting, sharing from the heart at a 12 step meeting, or telling a close friend or family member his true thoughts and feelings.

Assisting the client in developing a list of strengths and weaknesses is another direct method of attacking shame and increasing self-esteem. If the client cannot do this, ask for a list of his likes and dislikes. A client may be unable or unwilling to describe himself, but can usually express mild opinions: “I like mustard, I like football, I like summer. I do not like ketchup, hockey, and winter.” A list of simple likes and dislikes is often an entryway into a list of strengths and weaknesses.

Ideally, the clinician will provide a direct and honest appraisal of the client. In addition, the client can ask peers or family members for an assessment of strengths and weaknesses (assuming the clinician believes the client has the ego strength and insight to tolerate the results of this inquiry).

The shame-based client may insist that others tell him only his weaknesses which will, of course, perpetuate the negative self-image. Conversely, only praise for the shame-based client may inflate the ego, exacerbating narcissism and entitlement. A balanced view of the self must be given. Shame is best combated through honest appraisal, and not self-reproach or grandiosity.

The client next acknowledges these strengths. If he cannot tolerate hearing positive feedback, the focus must shift to helping the client accept such compassionate and truthful feedback from others. It is imperative that this feedback be sincere; insincere compliments will only erode the client’s faith in the other person’s truthfulness and credibility, and quickly damage the relationship.

The shame-based client will often ignore or minimize the positive words. The clinician might counteract such avoidance with a bit of humorous coaching to the client: “There is only one right response to a compliment – thank you!”

Through revelation and alteration, the client begins to see himself in a different light and is able to accept positive aspects of his personality. He gains a sense of hope and possibility. The shame-based client has been mired in lifelong negativity. He may now be able to say, “I’m no good sometimes,” or “I’m OK, but some parts of me need work” rather than “I am no good at all.”

Bibliography

Cognitive Therapy: 100 Key Points. Neenan & Dryden. Brunner-Routledge (2004).

Healing the Shame That Binds You. Bradshaw. HCI (1988).

Shame and the Adolescent. Ten Eyck. Corrections Today, Vol. 65, July 2003.

Shame on You: An Analysis of Modern Shame Punishment as an Alternative to Incarceration. Book. William and Mary Law Review, Vol. 40, 1999

Shame: Theory, Therapy, Theology. Pattison. Cambridge University Press (2000).

For the purpose of the online CE Course, the article objectives are: