The therapist’s ten commandments: “First – Do not shame”

Although shame is a very common psychological phenomenon, it is not given much attention in our culture. We like to talk about love, anxiety, jealousy, hate, vengeance or grief. But the topic of shame is frequently “the elephant in the room”. Perhaps, because discussion shame feels shameful itself… Nonetheless, understanding shame is crucial for comprehending how people behave in social interactions, so the topic is very important.

A while ago I had a first-time consultation with a depressed client. The appointment was meant to help us get to know each other and gather initial information. I learned among others that this was his first consultation ever with a therapist, so a part of our conversation dealt with the client’s expectations. After an hour or so the client was on his way out of the office and I followed him to the door. With his hand on the doorknob he hesitated, turned back towards me and said: “You know, on the way to you I was afraid of only one thing. I was afraid of hearing “pull yourself together!”…

What did his words mean? Well, many people who enter psychotherapy experience high level of shame and I interpreted my client’s words as a sign of relief of not being shamed by me – something he rather expected. A series of following consultations revealed his life-long history of being shamed by people with whom he had important relations.

Shame is a very complex topic and may be discussed from multiple angles, not only as an emotion. It has its biological roots, neurophysiological mechanisms, interpersonal functions, cognitive and behavioral components and cultural dimensions. A single blog article does not have enough space for such a broad scope. In brief, the tendency to experience shame, called shame-proneness, often stems from earlier experiences of being shamed by others, particularly significant individuals like parents, teachers, or partners. These experiences shape how people relate to themselves and others later in life. Even if the specific memories have faded, they will still impact interpersonal behaviors.

Shame can also be culturally derived. Society, family, and the groups we belong to provide us with clear hints on what kind of traits are undesirable and disapproved. If we find ourselves matching the criteria of disapproval, we may become ashamed of being who we are, even if we never met direct criticism or rejection. For instance, some people feel shame about their sexual preferences without ever being directly shamed by others, having simply learned that their desires are considered “wrong” by society. This same mechanism underlies the stigma surrounding mental health, causing many people to avoid seeking help due to the negative attitudes they’ve witnessed towards others with mental health issues.

Shame has many sources, and anything perceived as potentially causing social disapproval can elicit shame. For that reason, the list of possible shame-eliciting cues for our clients is practically endless. And here is the point: we can easily create the new ones during therapy, even being unaware of doing so.

There are several publications elaborating on the topic of shame and you can easily google something interesting about it on the internet. If you want to dive deeper into the subject, I recommend the book “Shame: Interpersonal Behavior, Psychology, and Culture” by Gilbert and Adrews. As it is impossible to discuss the topic of shame in depth in a single blog post, I won’t even try to do this, but one of the subtopics is especially important and worth mentioning here: the distinction between shame and guilt.

Brene Brown, made a helpful distinction between shame and guilt, pointing out that guilt is linked to behavior, while shame is linked to the Self. While experiencing guilt, we think “I did something bad”, while experiencing shame we think “I am bad”. Guilt is about my actions in my own eyes, while shame is about me as a person in the eyes of others. Both shame and guilt are unpleasant, but research has show that only shame is strongly linked to psychopathology (Hastings et al., 2002; Fergus et al., 2010; Kim et al., 2011).

Shame can be problematic in numerous ways.
As a social emotion, it regulates social hierarchy and protects groups from rule-breaking behaviors. In other words, shame protects the group from individuals, of course at the expense of individuals. Shame-proneness increases conformity, vulnerability to rejection, pliancy and susceptibility to group influence. In groups with a hierarchy based on popularity, shaming mechanisms give group leaders very strong control over behavior of group members. Stories of people who survived (or not survived) membership in religious cults illustrate how far group control may reach.

The power of shame has evolutionary roots, as the fear of being excluded from the tribe developed as one of the core mechanisms granting survival to our species. At the dawn of humanity, we lived in small groups moving through the African savannah, without any chances of survival if left alone. The fear of being excluded from the tribe and left behind still underlies a large part of human social motivation.

Being related to the self, shame is also toxic for our mental health through the changes it makes in the way we relate to ourselves. After being shamed and rejected by others, people may start to see themselves as the main cause of their misery in interpersonal relations. Thus they may turn against themselves with self-hate and self-attacking. This leads sometimes to heavy forms of psychopathology and to living extremely self-destructive lives.

Knowing all that, do we take into account shame and self-criticism in our therapeutic work? What kind of context do we create for treatment? Do we create a safe space in which our clients can feel secure from being judged and blamed by others and gradually adapt a more gentle and kind attitude toward themselves?

We all learn who we are through the lenses of the important others. Sometimes this view is extremely devaluating, harsh, unfair or even absurd. Therapy gives an opportunity to change it. And the way the therapist looks at the client has a powerful impact because of the therapist’s social role and status. So, what do our clients see looking at themselves through our lenses? How does the language we use to describe their problems impact that view? Does it boost self-respect or self-pity and shame?

Let’s have a look at the language used by therapists. Many terms we use to describe psychological problems have clear pejorative connotations. For instance, what do people hear when we talk about inflexibility? What is the word associated with? Or the word “avoidance”? How does it sound to be avoidant?

How about the concept of “giving up your values for avoidance”? What kind of person can be described this way? How about concluding that it applies to you after having read a text on a website, or listened to a trainer or lecturer? Would it increase your self-acceptance and self-respect?

In my clinical practice, I have met many clients who learned earlier in therapy that “they cause their own problems”, sometimes by “avoidance”, sometimes by “irrational beliefs”. Does it sound less critical and less blaming than “chemical imbalance” in the brain?

People may respond to shame in various ways. Some will franticly try to regain acceptance from others by submissive and pliant behavior. Some will withdraw from relation, hide and isolate. Some will adapt a more defensive stance and try to use aggression to neutralize the threat. This is what people often do in their social interactions while protecting themselves from shame and this is what you will see in your office when clients feel shamed, blamed and criticized.

But first of all, clients who are hypersensitive to shaming and criticism may easily get new fuel for their self-criticism after deriving blame from the therapist’s words. Then therapy would by like an attempt to treat burns by setting fire on them.

The role shame may play in treatment has been demonstrated among others in the study conducted by Randles and Tracy (Randles & Tracy, 2013). Subjects were recovering individuals attending alcoholics anonymous. They were videorecorded while responding to the question: “Describe the last time you drank and felt badly about it.” Those who displayed nonverbal signs of shame had greater relapse rate, the relapse was more severe, and over the next months their health declined more than the health of individuals displaying fewer signs of shame.

There are various ways of talking about psychological problems. Some of them have a bigger blaming potential than others. Intended or unintended, the impact they have on clients may be destructive. So, I would suggest to always look critically at models and metaphors used in communicating with clients, not only in a session but also when communication goes through indirect channels, such as blogs, public talks and popular articles. Quoting Hippocrates: “Primo non nocere” (“First, do not harm”)

One of my supervisees asked me recently “If you could write the therapist’s ten commandments, what would you put there?”. I do not have the whole list yet, but certainly number one would sound: “Do not shame”.

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Further readings:

Fergus, T. A., Valentiner, D. P., McGrath, P. B., & Jencius, S. (2010). Shame-and guilt-proneness: Relationships with anxiety disorder symptoms in a clinical sample. Journal of anxiety disorders, 24(8), 811-815.

Gilbert, P., & Andrews, B. (1998). Shame. Shame: Interpersonal Behavior, Psychopathology, and Culture: Interpersonal Behavior, Psychopathology, and Culture,

Hastings, M. E., Northman, L. M., & Tangney, J. P. (2002). Shame, guilt, and suicide. In Suicide Science (pp. 67-79). Springer US.

Kim, S., Thibodeau, R., & Jorgensen, R. S. (2011). Shame, guilt, and depressive symptoms: a meta-analytic review. Psychological bulletin, 137(1), 68.

Randles, D., & Tracy, J. L. (2013). Nonverbal displays of shame predict relapse and declining health in recovering alcoholics. Clinical Psychological Science, 1(2), 149-155.

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