Clinical implications of shame and guilt
In this essay I will define shame and guilt briefly, discuss their clinical implications and examine the need for modifications to the therapeutic relationship and CBT interventions. Literature suggests that guilt is less pathogenic than shame in vulnerability to psychological distress (Gilbert,2010,Tangney et al,1995), therefore this essay will be weighted towards discussion of shame issues.
Defining Shame and Guilt
Various texts discuss shame and guilt, their interrelationship and origins (eg Gilbert & Andrews,1998,Tangney & Fischer,1995,Tangney et al,1995). Both are unpleasant, undesirable emotions which nevertheless have some social function. In shame there is a sense of global negative self-judgement: "I am bad" whereas in guilt the perception is "I have done something bad"; that the individual has broken his/her moral code (Gilbert,1992), while the self remains relatively intact (Tangney et al,1995). This seems to be a fundamental distinction.
In shame the focus is inwards on the self and self-defence, with the drive to hide, conceal or escape. There is a fear of negative evaluation in the eyes of others, who are experienced as scornful or attacking (Gilbert,1992). Shame can be associated with perceived flaws in one's personality or physical appearance (Gilbert,2000b). People develop strategies to keep themselves safe, such as submission or appeasement, striving for achievement or conversely adopting an attacking stance to counteract shame. High levels of self-criticism are common.
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Guilt is based on responsibility for one's behaviour and harm done to others. It can be helpful in strengthening relationships whereas shame is not. The focus is more outward, with the desire to reach out and make amends, rendering guilt more accessible for work in therapy (Gilbert,2010). Guilt can co-exist with shame, for example if one's guilty actions are exposed, when it can be more problematic.
'The clinical challenge of shame is, first, to be aware of its existence and, second, to find means of coping with it other than hiding' (Tantam,1998)
Shame is often a vulnerability factor in depression, is usually linked with a more chronic presentation (Andrews,1998a), and can increase the likelihood of relapse (Gilbert & Proctor,2006).
One of the key implications for clinical work is the type of safety strategies people develop to cope with shame. These include submissive behaviour, avoiding development of trust and intimacy, and striving to be pleasing and acceptable (Gilbert & Proctor,2006). These can impinge on therapy, as can the drive to hide or conceal, rather than share and disclose. We all want to present a positive image to others and be perceived positively by them (Gilbert,1992). For patients with shame issues this can lead to concealment of true feelings and non-disclosure of significant information such as sexual abuse, domestic violence, or addictive behaviour. This may make assessment difficult or lead the therapist in the wrong direction. Significant information may be disclosed as the therapeutic relationship develops and the formulation will need to be reviewed in the light of this.
Gilbert (2009) demonstrates how safety strategies continually stimulate the threat system in the brain (Appendix I)and maintains that people with high levels of shame have usually not been soothed in childhood and consequently have never learned to self-soothe.
Andrews (1998b) makes links between shame, sexual abuse and depression. Patients may engage in several episodes of therapy without disclosing. Concealment can affect physical as well as mental well-being: Pennebaker (1997) describes the physiological effects of inhibiting distressing emotions. With hindsight I wonder if one patient's auto-immune problems could have been partly due to inhibition. I suspected that sexual abuse lay in the background, but it was months before she was able even to allude to this; a first disclosure at the age of 58. Her beliefs about being bad and disgusting impinged on her ability to disclose, and she was never really explicit.
Gilbert (1992) links shame with a fear of being treated with contempt or disgust by others. My patient was easily affected by the disapproval of others, especially powerful others (as a devout Catholic, her parish priest) and tended to withdraw. Religious belief added another dimension to her shame. It was difficult but rewarding work, and eventually she was able to share her experience with her husband and adult children.
Careful assessment is needed as patients often struggle to find words for their shame and it is easy to miss in therapy. Tangney et al (1995) refer to listening with a 'third ear' (p360) for shame experiences. Clues can include a sudden stop in the flow of narrative, shifting position, looking uncomfortable, breaking eye contact, blushing, and perspiring (Gilbert,1998a,Gilbert & Leahy,2007). Shame can affect cognitive processes, resulting in the "mind going blank" experience (Gilbert,1998a). Alternatively patients may display sudden anger, seemingly out of proportion. Scheff (1998) discusses bypassed shame, where the person becomes angry as a result of a shaming experience but this happens so quickly that they are unaware of feeling shame.
It seems important to remember that depressive symptoms such as psychomotor retardation, diminished concentration and withdrawal can themselves impede communication. Beck et al (1979) suggest that when depressed patients have difficulty articulating their distress, therapists may need to prompt or even guess. With shame these difficulties may be magnified. Patients may be ashamed about being depressed (Beck et al,1979), being seen as weak, neurotic or incompetent. They may conceal their depression from others, forfeiting the support they might have obtained. Guilt and shame can lead to a person feeling they are a burden and that suicide is the only solution (Gilbert,2000). Patients may be ashamed and guilt about having suicidal thoughts, and with shame particularly self-harming often occurs, so a thorough risk assessment is indicated.
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Fear of how the therapist might perceive negative information can affect disclosure, fuelled by the desire to be experienced positively in the eyes of others (Gilbert,2010). People with shame-based core beliefs fear further shame or exposure (Gilbert,1998b) and the consequent concealment can lead to feelings of being stuck in both therapist and patient. Use of supervision can help therapists to explore issues. Patients with high levels of shame may predict that therapists will react with anger or disgust, and terminate therapy (Gilbert,2000b). A patient I assessed was deeply ashamed that her husband had to remind her to wash and change her clothes. When her husband provided this information she wondered whether I would still be prepared to work with her.
Strategies developed to cope with shame affect people's relationships with others and their ability to enlist help, including attending therapy. They influence the way people cope with powerful emotions in therapy and whether they stay in treatment. Taking a history offers an opportunity to validate patients' experiences in a non-judgemental way and to begin de-shaming. Therapists need to emphasise that they understand how patients' strategies developed and to validate their efforts under difficult circumstances (Gilbert,2010). Although understandable at the time, strategies such as avoiding triggering situations or concealing feelings can have a role in maintaining problems, but the idea of changing them is usually very threatening. Therapists need to acknowledge this. It is also important to understand the thinking behind coping strategies, which can vary from: "Hide and you won't be found out" to: "Get in first and you won't be challenged" (Gilbert,1998b) which have different implications for therapy.
Perceptions of what is shaming can change over time (Lewis,1998). At the start of my career 25 years ago I met patients who had been institutionalised after conceiving an illegitimate child. Illegitimacy still carries social stigma in some societies, and therapists need to be aware of social, cultural and religious aspects of shame.
Tangney et al (1995) argue that guilt is not as strongly linked with propensity to depression as is shame. Guilt can be part of a depressive presentation, when it is often inappropriate or disproportionate. The authors suggest that guilt is not necessarily linked with psychological problems but that it can become pathological when linked with shame, leading to rumination and self-attacking. Beck et al (1979) caution against assuming that patients' guilt is appropriate, suggesting it is often linked with an excessive sense of responsibility for others. Therapy can help patients to stand back and look at the situation more rationally. The authors also suggest that there may be guilt about being depressed, due either to stigma associated with mental health problems or for being depressed when there is no apparent reason. They demonstrate the role of guilt in maintaining cycles of unhelpful behaviour such as alcohol abuse: drinking to excess, guilt about the drinking and more drinking to cope with the guilt.
The drive with guilt is to confess and make amends, so it may be easier to work with than shame as patients can be more open about their feelings. There is less resistance to disclosing and discussing guilt (Gilbert,2009,Macdonald,1998). As with shame it is important to explore social, cultural and religious values and therapists need to be alert to "should" and "must" statements.
The Therapeutic Relationship
Beck et al (1979) stress the importance of the therapist's ability to 'adapt his own personal style so that it meshes with that of the patient' (p27) when working with depression. The therapeutic relationship is influenced by the past experiences of both patient and therapist and Leahy (2007) considers the effects of schematic mis-match leading to possible ruptures. Hardy et al (2007) agree: 'Of paramount importance in maintaining the relationship is the therapist's ability to tailor therapy to the individual needs and characteristics of clients'(p34).
The therapeutic relationship needs to be very strong if shame is to be brought out into the open, and therapists need to be aware of their own shame issues (Tantam,1998). Therapists need to be particularly attentive to their own inner processes, and to transference and counter-transference issues. Therapists can be drawn into shame cycles, feeling a failure when patients do not progress: 'shame-prone patients can easily induce shame in others' (Gilbert,1998b,p256). There can be avoidance on the part of both patient and therapist when they can become engaged in 'a kind of shadow dance of skirting around central issues' (Gilbert,2000a,p125). It follows that when working with shame it will be necessary to slow the pace of therapy, allowing longer for the therapeutic relationship to become established. Beck and colleagues (1979) caution against rushing in with techniques and stress the need for sensitivity to patients' shame, allowing time for the groundwork of building trust.
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It is vital for therapists to demonstrate warmth and empathy, validating patients' deeply painful experiences and the strong emotions these engender. Greenberg (2007) suggests that this will assist patients to articulate their pain without feeling shamed and can activate the soothing system. He hopes that this might be internalised by patients who have not been soothed in childhood. Gilbert has written extensively about the need for compassion in working with high levels of shame (Gilbert,2005,2007,2009,2010) but both he and Beck et al (1979) warn against overly intense warmth, which depressed patients may perceive as threatening. Compassion may be associated with weakness or being kind to someone in order to exploit them. The emotional tone of therapy is important, as a caring environment may be extremely anxiety-provoking for some patients, decreasing the likelihood of disclosure (Gilbert,2010).
Therapists always need to be aware of their own and the patient's non-verbal communication, but need to fine-tune their antennae when working with shame. Moderating eye contact so it is not threatening, paying attention to facial expressions and tone of voice, and adopting a relaxed, interested approach is advocated (Gilbert& Leahy,2007). The authors suggest that reflecting is particularly important, helping patients who often feel a deep sense of aloneness to feel understood, and building the 'empathic bridge'(p12). 'The way a therapist is able to create experiences of safeness, often with the use of compassion, can be key to therapy progress, especially with high-shame and self-critical people'(p18).
An awareness of the potential power of the therapist-patient relationship is also needed. Patients with subjugation beliefs are likely to defer to the therapist and to feel inferior, as described in Gilbert's (1992) social-evolutionary approach to depression. They may hide any problems in the therapeutic relationship which give rise to shame because they fear a loss of status or loss of the therapist i.e. if the therapist disapproves of some revelation the sessions will be terminated. Sharing emotions can resonate with previous shaming experiences (Gilbert & Leahy,2007) which resulted in abandonment or punishment, and therapists need to beware of unwittingly compounding or activating patients' shame: for example using written handouts when a patient has literacy problems.
Taking time to develop the therapeutic relationship and build trust also applies to work with high levels of guilt, but disclosure is more likely due to the drive to confess and make amends. Therapists can emphasise that guilt is a normal emotion that everyone will experience, at the same time demonstrating empathy for patients' feelings. Pennebaker (1997) suggests that confession can be healing, and acceptance and understanding from the therapist can reduce feelings of guilt (Beck et al,1979).
Working with Shame
Paul Gilbert writes passionately about compassion in therapy (Gilbert,2005,2009,2010) and has developed Compassion Focused Therapy (CFT) (Gilbert,2010) specifically for patients with high shame and self-criticism. CFT uses many CBT interventions, but with a compassionate focus and some modifications. The emphasis is on helping people develop self-compassion by taking the view that how we arrive at who and where we are is not entirely our own doing, but is shaped by many factors, including early experiences. For people with high levels of shame these have usually been unhappy.
Salkovskis (1996) writes that working with safety strategies is about understanding how and why people have become trapped in these behaviours and exploring beliefs about them rather than labelling them "distorted" or "irrational". Such labels would be particularly unhelpful for high-shame patients. Safety strategies may literally have helped people to stay safe: the abused child monitors the abuser's moods and adapts her behaviour in the hope of avoiding violence (Gilbert,2010). Understanding this and taking a "not your fault" approach can help to reduce shame, encouraging people to take a step back and see how thoughts, beliefs and behaviours developed in response to circumstances (Gilbert & Proctor,2006).
Formulation is used as in all CBT, and central to this is the patient's sense of loneliness and not being understood. The formulation can shed light on problems in the therapeutic relationship and other relationships, showing how these might have developed and are maintained (Leahy,2008). Gilbert (1998b) has a helpful example of a case conceptualisation (Appendix II).
Gilbert (2010) advocates using Socratic questioning and guided discovery to develop idiosyncratic formulations rather than constructing a problem list. Patients need to understand the links between early experiences and safety strategies, and using a historical log (Padesky and Greenberger,1995)) can be helpful in updating autobiographical memories using standard techniques for modifying negative automatic thoughts.
The reasoning approach of CBT can be useful, but people need to make emotional connections too. 'It is when people make emotional connections that change can occur' (Gilbert,2010,p76). Therapists need to be genuine in their acceptance and validation of patients' emotions and allow time for those emotions to be experienced. Ill-timed questions or techniques can be experienced as dismissive by the patient, confirming that their feelings are invalid or unimportant (Leahy,2008). Sensitivity is needed in the use of silence, asking patients whether it is helpful or not. Some patients may experience silence as threatening or judgemental (Gilbert,2007).
Tangney et al(1995) endorse Beck's cognitive-behavioural interventions as shame can be linked with unhelpful beliefs and cognitions, and Gilbert (2010) agrees but stresses the importance of developing self-compassion first. Patients need to have a compassionate voice with which to "hear" the alternative thoughts generated in therapy. They are often able to understand the logical approach of CBT in weighing evidence for and against a belief or behaviour, but struggle to feel any different. Developing a compassionate mind is an important modification of this technique (Lee,2005). It is more helpful to look for changes in affect rather than in ratings of belief in cognitions, and important to check out whether apparent improvement in scores is borne out by the patients' presentation, given the need of some patients to please (Gilbert & Proctor,2006).
CBT interventions such as making changes, setting goals and desensitization to feared stimuli can be used, but with a compassion-based approach first (Gilbert,2010). As in CBT, CFT works towards changing unhelpful behaviours such as rumination or self-criticism, which stimulate the threat system. Patients are encouraged to engage in more compassionate behaviour, such as use of calming imagery or soothing breathing, engaging the soothing system. Gradual exploration of distressing emotions can be used in a similar way to desensitization. Therapists need to be containing and able to tolerate high levels of distress in order to provide a safe base for patients. Gilbert and Proctor's (2006) group used Socratic questioning, thought monitoring and re-evaluation, but focussed on developing self-compassion rather than directly challenging thoughts.
Gilbert stresses the importance of exploring the content of ruminations as well as addressing the behaviour. This may indicate where the focus lies: on the self in shame and on others in guilt. He cautions against getting into cognitive restructuring too soon, but it can be used if it seems helpful (Gilbert,2007).
Use of language is important: terms such as "thinking errors" or "cognitive distortions" can be invalidating and shaming for patients (Gilbert,2010). I prefer to use "unhelpful" generally, but for high-shame patients this can be vital. The word "homework" may activate shaming experiences from school, so an acceptable alternative needs to be found in collaboration with patients. When setting tasks it is important that patients are clear about the rationale for what they are doing, and it may be useful to write this down. A patient recently did not attempt tasks because his partner was scathing about them: a written rationale could have helped.
Working with Guilt
Therapists should not assume that a patient's guilt is appropriate; in depression it may be linked with an excessive sense of responsibility (Beck et al,1979). Asking the patient why they feel so responsible and encouraging them to stand back and look at the situation more rationally is advocated. This is often easier with guilt than with shame as guilt is associated with particular behaviours rather than with the self as fundamentally flawed. Using a 'responsibility pie' (Padesky and Greenberger,1995) can be helpful when working with guilt.
Patients who hold beliefs about always putting others first may experience guilt about attending to their own needs and the conflicting emotions involved can be explored in therapy (Gilbert,2000a). People may be applying high standards, such as being the perfect parent, and it can be helpful to discuss with others and explore their experiences. Activity Monitoring may reveal a good deal on these themes, but patients may need extra encouragement to engage in enjoyable activities for themselves.
Beck et al (1979) suggest using CBT techniques such as examining pros and cons or behavioural experiments to explore ways of changing behaviour in order to break out of guilt cycles. Patients may need to work towards accepting guilt feelings as part of the normal range of emotions. Cognitive restructuring can be used, but Gilbert cautions against introducing this prematurely (Gilbert,2000a).
From the evidence above it seems that many CBT techniques can be helpful when working with high levels of shame and guilt. Appropriate modifications as described can prevent these emotions being compounded in therapy. The therapeutic relationship is crucial and requires therapists to be compassionate and containing. Researching this essay has been extremely helpful clinically and when I am finding therapy difficult I will endeavour to remember that: 'Our patients are struggling the best way they can to survive or cope with great distress and we remain deeply respectful of that' (Gilbert,2007).
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