Shame-informed Counselling and Psychotherapy: Eastern and Western Perspectives 0367616181, 9780367616182

Table of contents :
Cover
Endorsements
Half Title
Title Page
Copyright Page
Contents
Figures
Tables
Foreword
Acknowledgements
Abbreviations
Part I: Understanding shame
1. Introduction
Why study of shame not emphasized
Centrality of shame
Overview of the book
Shame as a natural, primary emotion
Illustrations of shame-related cases
Book structure
Bibliography
2. Hiddenness of shame
Two-year study
Hidden behind secondary emotions
Is there shame?
Hiddenness as a notion of face
Psychological reasons for hiding shame
Uncovering hidden shame
Bibliography
3. Shame's dualistic nature
Two foci
Two functions
Two awareness
Two sources
Two indicators
Two states
Bibliography
4. Development stages of intensified shame
Shame in early childhood
Transgenerational shaming
Other social settings of shaming
Bibliography
5. My own struggles with shame
Growing up
Famous in school
Shame in loss
Graduate school
Bibliography
6. Empirical findings of my study
Past and present shame
Shame as mediator
Self-esteem vs shame
Education and shame
Bibliography
7. Qualitative findings of my study
Participants of the qualitative study
Data collection and transcription
Process precepts of data analysis
Phase 1: familiarizing with the data
Phase 2: generating initial codes
Phase 3: searching for themes
Phase 4: reviewing the themes
Phase 5: defining and naming themes
Phase 6: producing the report
Results of analysis
Intrapsychic consequences
Interpersonal consequences
Interpersonal findings
Bibliography
8. East-West distinctives
Shame in Asia
Illustration of Chinese cultural impact on shame
Guilt vs shame
Mundane with same dynamics at work
Bibliography
9. Healthy shame
Anticipatory shame
Vicarious shame
Clinical implications
Bibliography
10. Unhealthy shame
Acute shame
Internalized shame
Clinical implications
Bibliography
11. Continuum of shame
Prevalence of shamefulness
Prevalence of shamelessness
Continuum of shame
Incorporating the setting
Bibliography
Part II: Addressing shame
12. Getting to the roots
The typical approach to treat depression
Physiological and psychological causes
Why we develop the symptoms?
What can we conclude from here?
Bibliography
13. Connecting the symptoms to shame
Initial awareness of the link
Surfacing the shame
Making the connection
Bibliography
14. Preparing for shame-informed psychotherapy
Can past shame memories be changed?
Process of reframing through imagery
Enhancing the outcome with experiencing
Enhancing with symbolic acts
Bibliography
15. Application of shame memory reframing
Verbatim of Anne's case
Counteracting the inner vow
Recovering disowned parts of the self
Bibliography
16. Other antidotes to unhealthy shame
Self-affirming scripts
Self-acceptance
Judge not self
Judge not others
Bibliography
17. Therapist's skills
Recognizing shame
Handling client's resistance
Some online therapy skills
Termination of therapy
Bibliography
18. Therapist's shame
Self-awareness
Shaming and re-shaming
Setting too high expectations
Bibliography
19. Countering shamelessness
Social cohesion vs social unrests
Concern for rising shamelessness
Not socializing our children on shame
Application in society
Bibliography
Appendix: Summary of 2018-2019 study and its quantitative results
Participants
Procedure
Measures
Results
Calculation of statistical correlations
Bibliography
Index

Citation preview

SHAME-INFORMED

COUNSELLING AND

PSYCHOTHERAPY

EASTERN AND WESTERN PERSPECTIVES

Edmund Ng

“While guilt typically speaks to acts of commission, as well as acts of omission, the construct of shame has a more pervasive effect on a person and often emerges from the deeper and darker edges of the soul. Shameinformed Counselling and Psychotherapy: Eastern and Western Perspectives by Dr Edmund Ng is a definitive text on the subject and offers the reader a broad and rich cultural framework in which to view the therapeutic alliance. Counselling, at its core, is based on the nature and quality of the relationship between client and therapist, and successful outcomes are frequently dependent on bringing those things that are hidden into the light and a place of greater freedom in one’s life. Dr Ng masterfully addresses the interpersonal and intrapersonal nuances of shame, the inherent duality of its psychological dimensions, and presents clinical and practical strategies for both beginning and seasoned mental health practitioners”. Eric Scalise, Former Chair of Counselling, Regent University, USA, Senior VP, Hope for the Heart “Shame is ubiquitous in the therapy context—it is present in the attitudes and beliefs that discourage individuals from entering therapy in the first place, and it is also present throughout the work of therapy—regardless of therapeutic orientation. Moreover, empirical research has illuminated the many connections between shame and various psychological symptoms. However, what many don’t realize or account for is the reality that the experience and expression of shame is profoundly shaped by culture. What I appreciate most about Shame-informed Counselling and Psychotherapy: Eastern and Western Perspectives is Dr Ng’s nuanced, robust, culturallysensitive, and honest approach to the topic of shame. I believe his work is well-positioned within an area of need in our field and I am pleased to endorse it”. David C. Wang, Associate Professor of Psychology, Biola University, USA

“It is gratifying to read an in-depth exploration about the core human experience of shame from an Asian scholar and clinician who understands the complex dynamics of both the Eastern and Western psyche. Dr Edmund Ng appreciates the complexity and nuances of shame from the sociocultural, interpersonal and intrapersonal perspectives. I applaud his presentation of the healthy aspects of shame, as well as the pervasive debilitating impact of unhealthy shame. In this book, he is able to provide an approach to counselling those who struggle with unhealthy shame that is both informative and sensitive. Dr Ng’s insights are both clinically perceptive and compassionate”. Fred Gingrich, Professor of Counselling, Denver University, USA “Shame-informed Counselling and Psychotherapy: Eastern and Western Perspectives by Dr Edmund Ng is a clearly written, culturally rich, clinically creative, and personally transparent book that will be very helpful to clinicians as well as scholars and researchers. He points out that shame underlies many psychological problems and shows us how to empathically and effectively address shame in therapy. I highly recommend it as essential reading!” Siang-Yang Tan, Professor of Psychology, Fuller Theological Seminary, USA, Author of Counselling and Psychotherapy: A Christian Perspective “In Shame-informed Counselling and Psychotherapy: Eastern and Western Perspectives, Dr Edmund Ng explores a life span developmental perspective of shame that may be functional or dysfunctional. His thesis that shame is the root emotion of many psychological problems is poignant for clinicians in Asia and the West. Dr Edmund like myself were raised in a shame-based Chinese culture in Malaysia but trained in western theories of psychotherapy. We had to grapple with integrating the different East-West worldviews. Edmund’s book is the answer to our struggle with our cultural borderland utilizing the underlying theme of shame. It should be a required text for clinicians training to be cultural brokers in both the individualistic Western cultures and the collectivistic cultures of the East. Edmund artistically weaves a mixed research design and scholarly writing with practical suggestions for clinical practice. Further, his authentic selfdisclosure of struggles with shame and coping with the loss of his first wife makes Shame Informed Counselling and Psychotherapy an enlightening and valuable read”. Ben Lim, Professor of Marriage and Family Therapy, Bethel University, USA “This book fills a void in the psychotherapy and counselling literature and would be of great help to both the novice as well as the experienced

therapist. I enjoyed reading it not only for its heuristic content but also for the many personal insights it gave me, especially in the chapter where the author shares his own experience of shame. Dr Ng unpacks much of the complexities of this emotion. When I was in training, I was told that Eastern peoples, unlike Westerners, don’t feel guilt, but rather they feel shame. I knew this was incorrect and Dr Ng clearly shows that shame is a more basic underlying emotion that all peoples have, one that is often strenuously defended against. This well-referenced book gives good practical examples of conducting therapy to deal with shame. After reading it I think the issue of shame should play a more prominent role in our formulation of cases for therapy and in the training of therapists. This book is worthwhile reading for anyone in the psychotherapeutic field”. T. Maniam, Professor Emeritus of Psychiatry, National University of Malaysia, Kuala Lumpur

Shame-informed Counselling and Psychotherapy

Unhealthy or maladaptive shame is believed by many to be the root cause of a diverse range of mental health problems. If we want to offer a more reparative healing to people contending with these psychological issues, we must ultimately trace back and resolve their underlying shame. This book offers researchers, practitioners and students a balance of theoretical and empirical evidence for a practical approach in shame-informed counselling and psychotherapy. Drawing on empirical field study evidence on shame, and making references to both Western and Eastern literature on the subject, Ng advocates that shameinformed interventions be applied following or alongside the contemporary counselling modalities and protocols. Using his 15 years’ professional practice in the field, he offers a shame-informed counselling and psychotherapy approach which aims not merely to help the individual cope with or suppress the shame as commonly advocated in current literature, but also deals with its roots through the restructuring of core beliefs and early memories. Edmund Ng, formerly a business CEO, has been a licensed counsellor, grief therapist and psychotherapist in private practice for the last 15 years. Besides his qualifications in the field of business, he has studied doctoral courses in practical theology, counselling and psychology. He is accredited as a Fellow in Thanatology. Edmund has earlier written a book entitled The TIME Approach to Grief Support (2011).

Shame-informed Counselling and Psychotherapy Eastern and Western Perspectives Edmund Ng

First published 2021 by Routledge 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN and by Routledge 52 Vanderbilt Avenue, New York, NY 10017 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2021 Edmund Ng The right of Edmund Ng to be identified as author of this work has been asserted by him in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. British Library Cataloguing-in-Publication Data A Catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data Names: Ng, Edmund, author. Title: Shame-informed counselling and psychotherapy : Eastern and Western perspectives / Edmund Ng. Description: 1 Edition. | New York : Routledge, 2020. | Includes bibliographical references and index. | Summary: “Unhealthy or maladaptive shame is believed by many to be the root cause of a diverse range of mental health problems. If we want to offer a more reparative healing to people contending with these psychological issues, we must ultimately trace back and resolve their underlying shame. This book offers researchers and students a balance of theoretical and empirical evidence for a shame-informed counselling and psychotherapy approach. Drawing on empirical field study evidence on shame, and making references to both Western and Eastern literature on the subject, Ng advocates that shameinformed interventions be applied following or alongside the contemporary counselling modalities and protocols. Using his 15 years’ professional practice in the field, he offers a shame-informed counselling and psychotherapy approach which aims not merely to help the individual to cope with or suppress the shame as commonly advocated in current literature, but also deals with its roots through the restructuring of core beliefs and early memories.”-Provided by publisher. Identifiers: LCCN 2020035197 (print) | LCCN 2020035198 (ebook) | ISBN 9780367616182 (hardcover) | ISBN 9781003105732 (ebook) Subjects: LCSH: Shame. | Counseling. | Psychotherapy. Classification: LCC BF575.S45 N4 2020 (print) | LCC BF575.S45 (ebook) | DDC 158.3--dc23 LC record available at https://lccn.loc.gov/2020035197 LC ebook record available at https://lccn.loc.gov/2020035198 ISBN: 978-0-367-61618-2 (hbk) ISBN: 978-1-003-10573-2 (ebk)

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Contents

List of figures List of tables Foreword Acknowledgements Abbreviations PART I Understanding shame

1 Introduction

xi xii xiii xv xvii 1 3

2 Hiddenness of shame

11

3 Shame’s dualistic nature

19

4 Development stages of intensified shame

24

5 My own struggles with shame

29

6 Empirical findings of my study

34

7 Qualitative findings of my study

39

8 East-West distinctives

49

9 Healthy shame

55

10 Unhealthy shame

60

11 Continuum of shame

64

PART II Addressing shame

12 Getting to the roots

69 71

x Contents

13 Connecting the symptoms to shame

77

14 Preparing for shame-informed psychotherapy

83

15 Application of shame memory reframing

87

16 Other antidotes to unhealthy shame

93

17 Therapist’s skills

97

18 Therapist’s shame

102

19 Countering shamelessness

106

Appendix

111

Index

120

Figures

7.1 Final Thematic Map from One-time Focused Conversations 11.1 The ISS Psychometric Scale on Shame 11.2 A Proposed Comprehensive Continuum of Shame 11.3 A Proposed Dynamic Continuum of Shame 11.4 A Proposed Dynamic Continuum of Shame with Setting

42 66 66 66 67

Tables

7.1 7.2 13.1 A.1 A.2 A.3

Description of the Seven Participants Interviewed Participants’ Interactions with Other People Symptoms and What Ultimately Caused Them Descriptive Statistics of the 42 Participants Quantitative Survey Results Correlations among Shame, Social (In)validation, Grief and Other Personal Characteristics

40 44 78 112 115 118

Foreword

In this ambitious monograph, Dr Edmund Ng seeks to streamline and simplify our complex understanding of the healthy and unhealthy aspects of shame from both the Eastern and Western perspectives. In his two-year study which draws jointly on intrapersonal psychological theory and a social constructionist understanding of interpersonal dynamics in negotiating even our most intimate realities, he critically analyses the contexts and conditions that configure one unique form of bereavement, namely for women of Chinese cultural background living in Malaysia who suffer the loss of a hoped-for child through miscarriage, stillbirth, or in the earliest hours or days of life. Ng then moves on to make a novel empirical contribution to the field of bereavement and loss by studying not only the grief symptomatology of these bereaved women and the social invalidation of their grief experience, but also the shame that it engenders. To many people, the unrelenting pain of shame can be nearly unbearable, as often is the case in socially unrecognized and unsupported bereavement. As Ng usefully documents, there is considerable empirical evidence implicating shame as a root cause of many psychological problems. Further deepening his exploration of this disenfranchised loss, Ng adds to this quantitative study, with its reliance on carefully validated scales measuring key constructs, a qualitative study of a group of these women. The result is a mixedmethod investigation that accomplishes that rare convergence of rigor and richness, advancing an evidence-based argument for the role of shame and shaming in perinatal loss in this unique cohort, and sensitively offering insights into their lived experience and describing it in their own words. Ng then skilfully incorporates this insight on shame from an Eastern context into our current, mostly Western, body of knowledge about this primary human emotion to give us a wider and clearer perspective of shame by examining its hiddenness, dualistic characteristics, developmental influences, distinctive cultural features and key psychological dimensions. From such a framework, he builds up a more comprehensive continuum of shame that incorporates both its healthy and unhealthy components spanning from extreme shamelessness to extreme shamefulness as a psychological metric within the interpersonal context of a specific social environment.

xiv Foreword This model of shame with its wide relevance can help practitioners in fields such as psychology, counselling, social work, research and spiritual care to better plan and implement psychological interventions for shame in individuals as well as to confront the problems of shamefulness and shamelessness in society as a whole. It is against this backdrop that Ng proposes a model of shame-informed psychotherapy to address the problem at its roots through the reframing of shame-inducing memories that commonly reside at the level of the unconscious. With its rich implications for teaching, training, clinical practice and further research, I hope this monograph is widely disseminated and read by an international audience that stands to learn much from it. As an active scholar, researcher and practitioner, I know that I did. Robert Neimeyer, Professor Emeritus of Psychology, Director of Portland Institute, Author of 30 books

Acknowledgements

First of all, I am grateful to William Kirwan for introducing to me the concept and prominence of shame in the East. It was under the support and guidance of Robert Neimeyer that I did my two-year study on the psychological consequences arising from the recent perinatal losses of a group of Malaysian women with Chinese background, examining not only their grief, social invalidation and meaning-making experiences but also the shame that their losses engendered within an Asian culture. Despite his busy schedules, Neimeyer generously invested his time on me as a friend and mentor. I wish to express my gratitude to him also for writing for me the Foreword of my book. The same goes to my six esteemed peers, namely Eric Scalise, David Wang, Fred Gingrich, Siang-Yang Tan, Ben Lim and T. Maniam, who wrote for me their respective reviews. In addition, I am grateful for the many opportunities opened to me to speak on relevant topics in psychotherapy. These platforms accorded to me not only the gift of new friendships but also facets of insights as to what aspects of our human nature that merits further exploring in the Eastern context and where I can make a little contribution to benefit humanity as a whole. I hope Shameinformed Counselling and Psychotherapy: Eastern and Western Perspectives will fulfil a significant part of that aspiration. My editor Katie Peace deserves special mention for believing in me from the time I informed her of my study right through to the acceptance and publication of this book more than three years later. Her colleague Jacy Hui has also been most prompt in rendering whatever assistance that I needed from her. As an Asian, I believe that even as we have gained much from the contributions of Western writers with respect to our body of psychological knowledge and techniques, but given the contextual realities and cultural limitations, Asian writers also must rise up to contribute to this academic field from our Eastern perspectives. Therefore, I feel most honoured to be given the privilege to publish my book through Routledge. In our small family, my wife Pauline has been a pillar of encouragement and prayer for me ever since I started to work on this book. Our three children and their spouses were also helpful in showing me how to navigate my laptop screen

xvi Acknowledgements using some of the new IT manoeuvres which are basic to them but complex to people of my age group. So, in writing the book, I have learned about IT as much as I have in psychology. Last but not least, I want to thank all the people who have opened up their lives to me, granting me the privilege to be present with them as they talk about their deepest struggles and allowing me to share their most private pains and gains. In respecting their rights to anonymity and confidentiality, none of their actual names are quoted here and any close resemblances to their identities are to be considered as purely coincidental. Edmund Ng

Abbreviations

CBT DSM ECT ISS MHS PGW SNRI SPSS SSRI

Cognitive-behavioural Therapy Diagnostic and Statistical Manual Electroconvulsive Therapy Internalized Shame Scale Mental Health Services Psychoeducation Group Work Serotonin-noradrenaline Reuptake Inhibitors Statistical Package for the Social Sciences Selective Serotonin Reuptake Inhibitors

Part I

Understanding shame

1

Introduction

The last 150 years before the 1950s saw the rise of a new world order called modernism where secularism and the application of science was the order of the day. Knowledge exploded through empirical research. The understanding of human nature also became the object of intense methodical investigation. However, with regard to the human emotions, it was only in the latter part of the last century when we saw an emphasis on the study of shame (Berman, 2011). This is partly due to the fact that at the beginning years of modern psychology in the 1900s, Sigmund Freud who was then the prime mover of this new discipline, saw shame in relation to genital visibility, and hence it received comparatively little attention while the emphasis was on guilt. Indeed, Erikson (1950) stated, “Shame is an emotion insufficiently studied because in our civilization, it is so early and easily absorbed by guilt” (p. 227).

Why study of shame not emphasized There are other reasons why the study of shame has been generally neglected until the latter part of the last century. Besides the early preoccupation of the West with guilt over shame, Kaufman (1996) posited that there are strong cultural taboos surrounding shame. In addition, there is also the lack of an adequate universal language to describe such an emotion. Indeed, anthropologist Richard Shweder (2003) stated that although the nature of shame is invariant everywhere in the world, there are diverse ways of defining, experiencing, recognizing and communicating shame. Focused investigations into shame were also scarce due to the fact that shame as an affect is not easily studied. This is because shame is so painful that it is often disowned, denied or disapproved, and so shame mainly occurs outside of awareness or lies hidden behind secondary emotions such as anger, fear or grief (Lewis, 1971). Furthermore, Western psychological literature on the study of shame in the subsequent decades has mostly associated this emotion as being harmful or even pathological to a person’s well-being (Creighton, 1990; Kaufman, 1996; Schneider, 1977). For example, Western clinical definitions of shame referred to it as a negative and soul-destroying emotion. This included terminologies such as “a soul-eating emotion” (Jung, 1957, p. 23) or “a sickness of the soul” (Tomkins,

4 Understanding shame 1963a, p. 118). However, unlike the negative perceptions of this emotion in the West, shame is often seen more positively in the East. For example, shame in Chinese culture is also termed as a “human capacity that directs the person inward for self-examination and motivates the person toward socially and morally desirable change” (Li, Wang and Fisher, 2004, p. 769). Indeed, the perception backdrop of the global divide related to shame has appeared somewhat divergent, with the primary cultures of the West seen more as guilt-based, undergirded by a cause-and-effect mindset, while Eastern societies are said to have a shame-based worldview in their group-oriented thinking (Crystal, Parrott, Okazaki, & Watanabe, 2001; Sue & Sue, 2008). In other words, the individualism of the West implies that Westerners are more selfreliant, and hence they focus more on their guilt over their wrongdoings, while the collectivistic values of the East render Easterners more interdependent, and hence they are more concerned with their shame in the eyes of the community (Li, Wang, & Fischer, 2004; Muller, 2001; Nida, 1954).

Centrality of shame However, since shame is an emotion inherent in all humans, it is more accurate to say that the same dynamics of shame are seen in every culture, although they are patterned differently and to varying degrees in different societies (Peristiany & Pitt-Rivers, 1992). For example, Kaufman (1996) described American society as a shame-based culture, but there, shame remains hidden because the taboo on it is so strict that the people behave as if shame does not exist. Notwithstanding, Kaufman (1996) emphasized that “shame is the principal impediment in all relationships, whether parent-child, teacher-student or therapist-client” (p. 7), and that if we are to understand and eventually heal what ails the self, we must consider the effects of shame. In fact, shame has been called “the master emotion of everyday life” (Scheff, 2003, p. 239), and there is vast empirical evidence linking shame as the root emotion that causes many of our psychological problems (Harder & Lewis, 1987; Tangney, Wagner, & Gramzow, 1992). In other words, if we want to offer a more reparative healing to people contending with a diverse range of psychological issues, we must ultimately trace back and attend to their underlying shame.

Overview of the book Hence, this book first of all attempts to provide its readers with a wider and deeper understanding of shame that incorporates both the Eastern and Western perspectives before proceeding to present an appropriate approach on shame-informed counselling and psychotherapy to address shame as the root cause of many presenting mental health issues. In this book, I advocate that shame-informed approaches are applied following or alongside the contemporary evidence-based counselling or psychotherapy modalities and protocols to address the presenting psychological problems. In other words, shame-informed counselling and psychotherapy is used only

Introduction

5

as a supplementary intervention and not as a replacement of the first-level interventions. Addressing shame this way is more appropriate because most people do not seek professional help merely over their shame but over some other psychological manifestations, without having a clue that shame is the root cause of their problems. After or at some stage of the intervention process in helping the client work through and cope with the external symptoms using the therapist’s most favoured approaches, he or she will then focus on addressing the underlying shame. To help me gain a deeper and broader understanding of the full nature, dynamics and implications of shame that incorporates both the Eastern and Western perspectives, I undertook a two-year study in 2018–2019 involving a group of Malaysian Chinese women who live in the Eastern context and had experienced shame following their perinatal losses. Throughout the study, I made references to Eastern literature alongside what I have already learned about shame from Western studies as well as from my own clinical practice. The results of my study are presented as an Appendix of this book. The findings have helped to widen my understanding of shame and the approaches in addressing this emotion. These approaches are not merely in terms of coping or suppressing the shame as taught widely in current literature, but they deal with it at its roots through the restructuring of past shame memories.

Shame as a natural, primary emotion In essence, shame is a natural and primary emotion inherent in all humans just like fear or anger. Taking the example of fear, it serves to warn us to “fight, flight or flee” in the face of danger. But if we are very fearful over everything, then we become paranoia and are unable to function normally. On the other hand, if we are overly fearless even when standing face-to-face with a hungry bear, we will be devoured. Likewise, for shame, this natural and primary emotion in its functional and adaptive form is a healthy emotion to keep us more human by signalling our relational boundaries. As humans are social beings with a natural tendency towards group affiliations, we need to connect to others and not be excluded by them. Indeed, healthy shame helps to regulate our social behaviours by signalling to us when we have acted in an unacceptable manner outside of social norms. A fleeting or transitory experience of shame that is accompanied by an appropriate amount of external expression such as embarrassment, shyness, self-consciousness or discouragement signal others our admission of wrongdoing and readiness to make changes to avoid rejection. Others are in turn more likely to accept our conviction, stop condemning our misbehaviours and make allowances for us to remain connected. Thus, healthy shame can guide our social behaviour, aid social cohesion and even render us to be more empathetic and compassionate to self and others. However, it is also true that shame can also function maladaptively, which results in acute shamefulness or disavowed to give rise to shamelessness. Shamefulness or shamelessness will make us behave irrationally. Indeed, neuroscience tells us that when shame is evoked, there is a highly destabilizing

6 Understanding shame emotional reaction that triggers the panic emotional system. Sensations and images now have difficulty flowing as a coherent whole. As high activation of the limbic system corresponds with reduced activity of the prefrontal cortex, our emotion regulation often fails at this point (Panksepp, 2005). Emotion dysregulation results in an impairment of the higher order processing essential for good decision-making (Gross & Thompson, 2007; Mende-Siedlecki & Ochsner, 2011; Phan & Sirpada, 2013). It means that our logical thought processes are now unavailable to regulate the right brain. In view of this impairment, people can start to behave irresponsibly. A similar emotion dysregulation is also involved when shame is disavowed. In fact, shamelessness will cause more harmful and blatant public misbehaviours in society than shamefulness. Therefore, we need to understand well both the healthy and unhealthy dimensions of shame before we can know how best to check and balance this emotion to our best advantage.

Illustrations of shame-related cases Nathanson (1993) described the Compass of Shame to represent four typical sets of affect management scripts to defend against the painful experience of shame. The strategies and techniques are placed under four categories: (a) withdrawal, (b) attack-self, (c) attack-other and (d) avoidance. They govern the feelings, cognitions and behaviours that constitute the reactive phase of the shame experience. As a result of these defences, what we see externally are psychological manifestations that mask the shame, and unless we address the shame, the root cause of the manifestations is not resolved. Described here are four typical cases that I have often attended to in my professional practice to illustrate each defence. These cases, in particular the first one, will be further followed through in more detail in the rest of this book. Withdrawal refers to the physiological actions of shame affect such as hiding, acting shy, running away and growing silent. Withdrawal from shame is likely the root cause of feelings of loneliness and emptiness. In addition, the Compass of Shame links withdrawal with distressful and fearful behaviours, sexual impotence and frigidity as well as clinical depression. In this respect, I was once referred a very depressed student named Anne who could not continue with her final-year studies in an American university. That was after seeing a psychiatrist and a student counsellor to help her cope with depression for one whole year before her father persuaded her to give up everything and come back home. While attending to her depression the conventional way, I also discovered that in her school days, she was constantly shamed by her teachers for not completing her homework. To avoid further exposure to shame, she had set high expectations on herself. At the same time, she became extremely shy even to the extent of avoiding to ask questions on what she did not know. Unfortunately, she came to a breaking point in her final year when she could not catch up with her studies, and her mind went totally blank. Besides addressing her depression with cognitive behavioural therapy techniques, I also attended to her shame, freed her from her withdrawals

Introduction

7

and restored her confidence. She eventually recovered from her depression, went back to her studies and successfully graduated from her course. Attack-self is a strategy to protect oneself from being shamed by intentional derogation such as ridiculing or exhibiting anger towards oneself. External manifestations of attack-self include deference, conformity, self-disgust, masochism and obsessive-compulsive behaviours. I once treated a client named Patty who compulsively washed her hands many times after going to the toilet or bathroom. I initially tried using exposure and response prevention techniques on her, but this only helped her to cope superficially with her compulsive behaviour without getting to the root of her problem. I eventually learned that when she was a child, she perceived that her father molested her and she grew up ashamed of her “dirtiness”. Whenever she touched her underwear, she would feel dirty and so she constantly washed her hands to get rid of the dirtiness as a form of self-punishment. To bring about the structural change at the level of her core beliefs and early memories, I attended to her shame by bringing her back to the original incident of the “sexual abuse”, led her through an emotional reframing experience and finally delivered her from her shame and compulsive behaviour. Attack-other is a defence to feel better from the experience of shame by reducing the self-worth of another person. External manifestations include putting down others, ridicule, contempt, public humiliation, fighting and vandalism. In addition, the Compass of Shame associates attack-other with sexual sadism. I once counselled a couple of which the wife Cindy was often abused physically by her husband called Norman. My initial intervention of couple therapy techniques like reframing, reappraisal and empathy-based collaborative alliances as well as anger management strategies had made some but limited difference to the ongoing violence. After some time, I began to focus on the man’s shame. I found out that when he was a child, his parents used to shame him for not doing as well as his younger sister in their studies. He grew up with a high sense of inferiority towards younger women and each time he felt insulted or disrespected, whether in the family or at work, he would take it on his younger wife. I gave him the insight of what made him “attack-other” as a defence against his own shame and helped him to embrace the truth that his self-worth is not based on how other people see him but on what he is as a unique individual who is no less than anyone else. After further intervention in shame memory reframing, their marriage had improved remarkably without further incidences of domestic violence. Avoidance is the fourth strategy to make the experience of intense shame go away by some form of distraction. This include the pursuit of pleasure and other self-indulgent activities, drug addiction, gambling and so on to disavow any sense of shame in them. In addition, the Compass of Shame associates avoidance with narcissistic personality and sexual machismo. Alex was brought to me for counselling by his wife as he was addicted to gambling and the family was on the verge of breaking-up. I initially utilized the normal evidence-based intervention

8 Understanding shame protocols which included cognitive restructuring and financial/time management training (cognitive-behavioural therapy) as well as the imaginal desensitization techniques (Behavioural Therapy). Alex eventually stopped his gambling activities, but he complained that he had to exercise a lot of effort and will power to manage his urges and he desired to be set free more completely. I explained to him that ultimately, his addiction is a form of escape and distraction from his overwhelming shame built-up since his childhood days. It is a substitute for relationships and a way to avoid intimacy and closeness due to the lack of relational worth. Alex then revealed that when young, he constantly experienced shame as he was placed by his widowed mother under the care of a domestic maid who had often rejected and abandoned him. After the supplementary intervention on shame, Alex reported that he sensed he had a genuine break-through from his gambling urges.

Book structure More and more people are seeking therapy for mental health problems ranging from depression and violence to obsessive-compulsive disorders and addictions, without a clue that the underlying cause of their external symptoms is shame. At the same time, anxieties on shame are also on the rise as parents’ expectations on their children are becoming higher, more dysfunctional families are passing down their unresolved secret shames to the next generation through humiliation and intimidation, and the social media has emerged as a daily platform for comparisons and one-upmanship in appearance, possessions and performance, thus serving as a major source for brewing shame. Such shame anxieties intensify the sufferings of those already trying hard to cope with their existing mental health problems. The result is the increase of shamefulness and shamelessness as a global trend in our societies. Yet there are hardly any solid educational modules on addressing shame being taught in the counselling courses offered by the tertiary institutions. Above all, this book is written as a contribution to therapists who bemoan the fact that shame is notoriously difficult to admit, discuss and treat (Dearing & Tangney, 2014; Lewis, 1971; Lindsay-Hartz, 1984). Part 1 of the book provides the theoretical concepts of the psychological construct of shame. Chapter 2 starts by highlighting the hiddenness of shame and explains the psychological dynamics making it as such. The paradox is that despite the need to hide shame and fear its exposure, yet there are times when it is better to reveal our shame due to our innate human need to belong and be included socially. Chapter 3 further expands on the dualistic characteristics of shame in terms of two functions, two foci, two loci, two awareness, two sources, two indicators and two states. Shame’s duality makes it a complex emotion to study and understand. Chapter 4 then proceeds to trace the development of shame from early childhood to adulthood and shows what typically happens when normal and healthy shame is turned maladaptive to become acute and internalized. To further illustrate the developmental aspects of shame as discussed earlier, some of my own struggles with shame are personalized and highlighted in Chapter 5.

Introduction

9

Chapters 6 and 7 summarize the key quantitative and qualitative findings of my two-year study on the shame dynamics experienced by Chinese women following their perinatal losses. The study is carried out in an Eastern context and the following Chapter 8 places the findings against the backdrop of the East-West distinctives in the perceptions and expressions of shame in their primary cultures. For the rest of Part 1, the focus is on the psychological construct of shame. In Chapters 9 and 10, the basic components of healthy and unhealthy shame are, respectively, identified and named. Using these basic components, a complete continuum of shame spanning from shamefulness to shamelessness is presented in Chapter 11 to provide a solid platform for us to learn how to address shame in a more effective way. Part 2 of the book covers the application aspect of shame-informed counselling and psychotherapy. Chapter 12 starts by uncovering the basis for addressing shame as the root of many psychological problems, while Chapter 13 shows how those symptoms can be connected to shame. Chapter 14 lays the groundwork to prepare for shame memory reframing and Chapter 15 shows the how-to process illustrated by the verbatim of a typical intervention. The book concludes by covering on four complementary but important subjects, first touching on the other antidotes to healthy shame in Chapter 16. This is following by an account on the therapist’s skills in Chapter 17 and the therapist’s shame in Chapter 18. Finally, Chapter 19 offers some proposals to address rising shamelessness at the individual and society levels. The quantitative data and results of my two-year study are shown as an Appendix to the book. Throughout the book, a distinction has been made between the techniques and levels of intervention in counselling and psychotherapy. The main difference is that counselling involves psychological techniques more intended to help people cope with their present mental health difficulties, whereas psychotherapy attempts to resolve the roots of the present problems by going back to the past and childhood experiences to restructure the unconscious memories. In other words, counselling is mainly supportive and re-educational, while psychotherapy is supportive, re-educational and reconstructive (Wolberg, 1977). Apart from the distinction made with regard to the techniques and levels of intervention of these two terms, the words counsellor, psychotherapist, clinician and practitioner as professionals in this discipline are used interchangeably. Likewise, the words client, counselee and patient, and words on gender such as he or she are also used interchangeably.

Bibliography Berman, J. (2011). Exposing shame. Death Studies, 35(8), 768–774. Creighton, M. R. (1990). Revisiting shame and guilt cultures: A forty-year pilgrimage. Ethos, 18, 279–307. Crystal, D. S., Parrott, W. G., Okazaki, Y., & Watanabe, H. (2001). Examining relations between shame and personality among university students in the United States and Japan: A developmental perspective. International Journal of Behavioral Development, 25, 113–123.

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Dearing, R. L., & Tangney, J. P. (2014). Introduction: Putting shame in context. In R. L. Dearing & J. P. Tangney (Eds.), Shame in the therapy hour (pp. 3–19). Washington, DC: American Psychological Association. Erikson, E. H. (1950). Childhood and society. London, England: W. W. Norton. Gross, J. J., & Thompson, R. A. (2007). Emotion regulation: Conceptual foundation. In J. J. Gross (Ed.), Handbook of emotion regulation (pp. 3–24). New York, NY: Guilford. Harder, D. W., & Lewis, S. J. (1987). The Assessment of shame and guilt. In J. N. Butcher, & C. D. Spielberger (Eds.), Advances in personality assessment (Vol. 6, pp. 89–114). Hillsdale, NJ: Erlbaum. Jung, C. G. (1957). The undiscovered self. New York, NY: American Library. Kaufman, G. (1996). The psychology of shame: Theory and treatment of shame-based syndromes (2nd ed.). New York, NY: Springer. Lewis, H. B. (1971). Shame and guilt in neurosis. New York, NY: International University Press. Li, J., Wang, L., & Fischer, K. W. (2004). The organization of Chinese shame concepts. Cognition and Emotion, 18(6), 767–797. Lindsay-Hartz, J. (1984). Contrasting experiences of shame and guilt. American Behavioural Scientist, 27(6), 689–704. Mende-Siedlecki, P., & Ochsner, K. N. (2011). Emotion regulation: Neural bases and beyond. In J. Decety & J. T. Cacioppo (Eds.), The Oxford handbook of social neuroscience (pp. 278–284). New York, NY: Oxford University Press. Muller, R. (2001). Honor and shame: Unlocking the door. Philadelphia, PA: Xlibris. Nathanson, D. L. (1993). About emotion. Psychiatric Annals, 23(10), 543–555. Nida, E. (1954). Customs and cultures. New York, NY: Harper. Panksepp, J. (2005). Affective neuroscience: The foundations of human and animal emotions. New York, NY: Oxford University Press. Peristiany, J. G., & Pitt-Rivers, J. (1992). Honour and grace in anthropology. Cambridge, England: Cambridge University Press. Phan, K. L., & Sirpada, C. S. (2013). Emotion regulation. In J. Armoney & P. Vuilleumier (Eds.), The Cambridge handbook of human affective neuroscience (pp. 376–394). Cambridge, England: Cambridge University Press. Scheff, T. J. (2003). Shame in self and society. Symbolic Interaction, 26(2), 239–262. doi:10.1525/si.2003.26.2.239. Schneider, C. D. (1977). Shame, exposure, and privacy. Boston, MA: Beacon. Shweder, R. A. (2003). Toward a deep cultural psychology of shame. Social Research, 70, 1109–1130. Sue, D. W., & Sue, D. (2008). Counselling the culturally diverse: Theory and practice (5th ed.). New York, NY: Wiley. Tangney, J. P., Wagner, P. E., & Gramzow, R. (1992). Proneness to shame, proneness to guilt, and psychotherapy. Journal of Abnormal Psychology, 101, 469–478. doi:10.1037/0021-843X.101.3.469. Thompson, C. (2015). The soul of shame, retelling the stories we believe about ourselves. Downers Grove, IL: InterVarsity Press. Tomkins, S. S. (1963a). Affect, imagery, consciousness: The negative affects (Vol. 2). New York, NY: Springer. Wolberg, L. R. (1977). The technique of psychotherapy (3rd ed., Parts 1 and 2.). New York, NY: Grune & Stratton.

2

Hiddenness of shame

Before we can address shame effectively, we need to understand the nature of shame thoroughly. To help me gain a wider understanding on shame that incorporates both the Eastern and Western perspectives, I also referred to Eastern literature on the subject to add to what I already knew through studying the psychological literature of the West. In addition, I undertook a two-year study on shame to supplement my understanding of it from my clinical experience in attending to clients with mental health issues rooted in shame. To begin with, this chapter will look at the hiddenness of shame amidst its social characteristics.

Two-year study Shame is defined in the Merriam-Webster Dictionary as a painful emotion caused by consciousness of guilt, shortcoming or impropriety, alternatively, a condition of humiliating disgrace or disrepute. In the field of psychology, shame has been simply referred to as rage turned against the self (Erikson, 1950) or feeling bad about oneself (Tangney, Wagner, Hill-Barlow, Marschall, & Gramzow, 1996). When a person is ashamed, the head hangs, the eyes are lowered and the gaze is averted. Blushing compounds shame, causing one to feel ashamed of shame. Indeed, “The exposure inherent in shame creates the sense of nakedness before an audience: it feels as if others can see inside of us or actually read our thoughts” (Kaufman, 1996, p. 18). Theoretically, a person will feel shameful when one perceives he is falling short of his own expectations on himself or what others expect of him. This is the gap which Sandler, Holder, and Meers (1963) termed as the difference between the ideal self and the actual self. The ideal self is what the person aspires to, whereas the actual self is what the person finds himself as he actually is. The greater is the gap, the more intense is the shame in a given setting. Different settings also offer different expectations on the individual, significant others and society in general to generate different intensities of shame. My two-year study on shame was done in an Eastern setting, and it was undertaken in 2018–2019. The study involved 42 Malaysian women of Chinese background. Each of them had experienced a perinatal loss within the last three years. A perinatal loss refers to the death of an infant during pregnancy or soon

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Understanding shame

thereafter. There are different types of perinatal losses, including miscarriage, stillbirth and neonatal deaths. A miscarriage is the body’s natural termination of pregnancy before 20 weeks of gestation. A stillbirth is a foetal death after 20 weeks of gestation. Most people consider life starts at the first month of pregnancy. A neonatal death occurs when an infant dies within the first month following a live birth. The most common form of perinatal loss is miscarriage. For the quantitative section of my study, I had asked the participants to provide their relevant demographic and contextual information such as the type of perinatal loss, their age, level of education, religious background, number of children, time lapse since the loss and the perceived impact of any childhood shaming incidents on their lives. They were also asked to complete three selfreport questionnaire surveys on shame, grief and social (in)validation. Further details of the surveys, participant characteristics collected prior to the commencement of the surveys, and the survey results and the statistical analysis are provided in Appendix.

Hidden behind secondary emotions I also had one-time focused conversations with seven of the same participants to examine qualitatively the various types of emotions experienced by them following their miscarriage, stillbirth or neonatal death. From the interviews, it was found that guilt, anger, anxiety and sadness were the foremost emotions sensed and expressed by them. For example, an office administrator by the name of Ivy (identified in the survey as P22) wondered, “What if I have not worried so much as to how we will cope with another child when we are both already so busy, would I have carried him to full term?” Likewise, a secretary called Tricia (P33) regretted by saying “Why I had installed the air-con unit in the living room? You know, we Chinese have this “pantang” (superstition) not to hammer nails during one’s pregnancy!” The “what if” and “why” questions are clear indications of guilt. They were feeling guilty for what one had done or not done. Anger, whether at self or the doctor or God, is also a common first reaction in times of frustration over the perinatal loss as one attempts to find convenient targets of blame for one to be angry at. For instance, Amy (P01), a dentist by profession, exclaimed, “It’s unfair! I asked God, ‘Why one time of miscarriage is not enough; then a second time and now one more time?’” Also, Emily (P23), who is a housewife, said, “I was angry at myself for not welcoming my third child when I conceived him. At that time, I thought that having two children is enough for us.” Then there is the typical expression of anxiety, like “What’s next? Is God going to take away my husband too?” (Amy, P01), or “Will I be able to have any children at all?” (Susan, P02, banker). Of course, sadness is often felt alongside anxiety and the other emotions mentioned earlier. Tricia (P33) bemoaned, “I was very sad, crying every day for one month. During that month, I did not even taken care of myself.” A property executive called Jo (P07) was illustrative when she said, “I am involved in running a shopping complex. Whenever I come to a

Hiddenness of shame 13 retail shop selling baby products with pregnant women inside, I will make a turn around and walk away because all those sad memories will come flooding back.” It is noted that not one of the participants initially admitted feeling any sense of shame, although in typical Chinese culture, women who have suffered a perinatal loss are expected to feel shameful for failing to give birth when other women had succeeded in doing so. Indeed, Confucian tradition holds that children are a symbol of blessing and family continuity (Wu, as quoted by Lou & Chan, 2006), and so losses through perinatal deaths are shameful for the mother for bringing shame to the family name in not fulfilling her expected role and duty to bear children.

Is there shame? Shame is nevertheless present. As a case in point, Amy (P01) first remarked as follows: “Since miscarriages are so common, I ought not feel shameful over the loss.” However, she later narrated the following incident: When I returned to my clinic, there was a dental patient who learned about my absence from work due to my miscarriage and she tried to share with me about her own miscarriage. I did not open myself up and talk more with her. I regretted over this. Maybe I was ashamed about my own loss. Likewise, Liza (P02, a social worker) initially declared that, “I felt guilty and angry at myself. I was sad but there weren’t any feelings of shame.” But then she subsequently said: Sometimes I feel inadequate and fearful of what others will think of me after the loss. Actually, I don’t feel as adequate as before and, in a sense, there is shame. I can go so low, face the ground, like I am in another place. From the quantitative perspective, the survey on shame completed by the 42 participants utilized the Internalized Shame Scale (ISS) developed by David R. Cook in 1994. The ISS is currently the most promising psychometric instrument for the empirical study of shame (Viken, Hassel, Rugset, Johansen, & Moen, 2010). For the purpose of my study, the ISS questions were modified slightly by putting in the words, “Following the loss” to direct the participant’s attention to what she was experiencing following her perinatal loss, as in the following example: “Following the loss, I feel like I am never quite good enough for anything.” The reliability analysis of the ISS questionnaire used in my survey demonstrated a very strong internal consistency for shame in the current sample (α = 0.97). The results showed that there was indeed some sense of shame in all of the seven participants being interviewed by me, with scores ranging from 8 to 40, while Jo (P07) had the highest score of 54 among them. The ISS scale specifies scores of ≤49 as low shame, whereas the score of 50 to 59 refer to frequent experience of shame.

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Understanding shame

In fact, shame need not be admitted per se but words such as being “inadequate”, “worthless”, “dirty” and so on are indicative enough to betray the inner feelings of shame. For instance, Liza’s (P02) remarks that “I feel inadequate and fearful of what others think of me after the loss” is an insightful description on how she felt shameful about herself. Indeed, Nicols (1992) pointed out that, “we feel shame for being weak and worthless … it involves a negative judgement upon who we are, and our self-worth as a human being” (p. 40). Tangney (1992) also stated that in shame, the focus of awareness is on oneself as the object of negative evaluation by others. In this context, Jo’s (P07) statement is particularly pertinent: “I started to compare with others of the same age and asked myself why I cannot give birth. Am I so worthless?” This is the language of shame.

Hiddenness as a notion of face Many studies have suggested the greater prevalence of shame among the Chinese relative to Western people (Dunn, Bretherton, & Munn, 1987; Fisher, Shaver, & Carnochan, 1990; Fung, 1999; Shaver, Wu, & Schwartz, 1992; Stipek, 1998). Hence, one initial key finding of my study is that even in the East where shame is known to be more prominent than in the West, this emotion is just as hidden and not readily admitted and expressed. It was stated earlier that shame is hidden in American society because the taboo on it is so strict that the people behave as if shame does not exist there (Kaufman, 1996). So why is shame just as hidden in the East? Based on the notion of face, a culture-specific explanation for the hiddenness of shame can be offered. Goffman (1967) defines face from the Western perspective as the individual consciousness of his or her public image. His definition of face in the West is self-orientated, individual-based and rational. On the other hand, Chang (2008) reviewed the Chinese literature on face (lian or mianzi) and concluded that the Chinese notion of face is other-directed, relational and moral. It is rooted in relations (kuan-hsi) and so face is shared by people in relationships. She states, Deeply rooted in the Chinese concept of face are conceptualizations of a competent person in Chinese society: one who defines and puts self in relation to others and who cultivates morality so that his or her conduct will not lose others’ face. (p. 303) Premised upon these two different notions of face, we can see that shame is seldom expressed in the case of perinatal losses in Western people not because there is any strict taboos against a miscarriage, for example. Indeed, it is perceived that the biological loss of a child during pregnancy has nothing to do with the competency of the mother in its self-orientated, individual and rational sense and therefore there is nothing to be ashamed of. So, for Western people, shame is hidden probably because there is simply shame against the expression of shame per se and this is the taboo which Kaufman (1996) referred to.

Hiddenness of shame 15 For the Chinese, competency is seen in relation to others. Not being able to bring the child to full term is perceived as a failure on her role as a mother to bless her family with offspring. It is thus shameful, but expressing that shame will implicate the loss of face of the other members of the immediate and extended families in the eyes of the community. Indeed, we see that Liza’s (PO2) fear “of what others think” and Jo’s (P07) urge “to compare with others of the same age” are rooted in the notion of shared face which prompted their unconscious tendency to hide their shame at the first instance.

Psychological reasons for hiding shame How then can we explain the hiddenness of shame from the psychological perspective? First of all, we have seen that the underlying psychological dynamics why shame is not readily admitted is due to the fear of being found “less than” others when compared to them. So, in controlling what we reveal about ourselves, we “play it safe” to minimize the risk of exposure to shame. Putting it in another way, shame is also often not initially admitted because there is “shame of shame” (Kauffman, 2014), so that shame remains hidden underneath the other emotions such as guilt, anger, anxiety or sadness. Indeed, Scheff (1997) wrote as follows: “Shame is the most frequent and possibly the most important of emotions, even though it is usually invisible” (p. 210). Shame of shame arises because shame is unpleasant to bear. When we want to talk about it, we have to get in touch with its unpleasantness and so to feel less discomfort, we would rather focus on the secondary emotions set off by the underlying shame. These secondary emotions are those more readily recognized without feeling too much the unbearable pain of shame. In this respect, Tomkins (1963) further avers that shame is the basic affect underlying guilt. The Merriam-Webster Dictionary’s definition of shame as a painful emotion associated with the “consciousness of guilt” lends evidence to Tomkins’ statement, but in terms of causal effect, the dictionary’s definition of shame as a painful emotion caused by the consciousness of guilt is wrong. It is shame that sets off guilt, not the other way around. The reflexive response to guilt is self-blame (Kugler & Jones, 1992). Following the self-blame, one can confess, punish, forgive oneself or make other amends, but in shame, there is no clear remedy for one to take (Lindsay-Hartz, 1984). The same can be said of anger which can be vented; anxiety which can be addressed through relaxation and other normalization techniques and sadness which can be experienced as a grieving process. This may explain why guilt, anger, anxiety and sadness were the emotions more readily recognized and admitted by the seven participants during the one-time focused conversations to talk about the emotional experiences of their perinatal losses, but shame remained initially concealed. Alternatively, people will use other less threatening or synonymous words such as embarrassment, shyness, self-consciousness or discouragement, when what they feel inside is really shame. Kaufman (1996) called these external expressions that mask the recognition of the underlying affect of shame as shame complexes.

16

Understanding shame

Due to the aforementioned phenomenon of shame, we do not verbalise shame readily and many of us are compelled to suffer in silence. Bottling up shame actually intensifies it and creates the need to mask it. As we will see later, this leads to adverse self-evaluations and core beliefs, which trap the person in a continuous cycle of shame.

Uncovering hidden shame Notwithstanding the hiddenness of shame, this affect also has a social nature that is related to our innate human need for belonging and inclusion in a social group. This social characteristic of shame has been discussed in Chapter 1. The threat of social exclusion set off by underlying shame will evoke a deep anxiety within us. Hence, both Kaufman (1995) and Keltner, Young, and Buswell (1997) argued that shame is evoked when a person’s secured social bond is threatened or disrupted. This means that hidden shame is accessed by our awareness more readily when our attention is directed at the interpersonal level within a social context, where real or imagined. Hence, we see that in the case of Amy (P01, dentist) as described previously, her hidden shame was more readily evoked when she was narrating to me her incident with her dental patient back in her clinic. In view of the hiddenness and social nature of shame, the measurement of shame may hence be more effectively carried out if the questions to assess it are phrased at the interpersonal level within the context of a social situation. This calls for an assessment that is more projective in nature in which the respondent is projected into a social situation, whether real or imagined, where shame can be potentially evoked so as to draw it out from its hiddenness. As an illustration, Question 1 of the ISS states, “I feel like I am never quite good enough”. Such a question can be rephrased at the interpersonal level within the context of a social situation as follows: If I am in a class where the teacher asks for a volunteer to present a piece of homework given to all the students, I often don’t volunteer because I feel I am never quite good enough. Likewise, Question 2 of the ISS, which states, “I feel somewhat left out” could be rephrased as follows: Whenever I am not invited to a social function like a wedding or birthday party, I feel somewhat left out due to my unattractiveness or inadequacy. Particularly in the Eastern context, such a projective questionnaire could help to better access hidden shame and thus give a more accurate assessment of this affect. Likewise, when clients enter into therapy, they are often unable to link their distress or presenting symptoms to shame. Phrasing our questions at the interpersonal level within the context of a social situation will serve the same purpose to help clients better access their hidden shame.

Hiddenness of shame 17

Bibliography Chang, Y. Y. (2008). Cultural “faces” of interpersonal communication in the U.S. and China. Intercultural Communication Studies, XVII, 1. Cook, D. R. (1994). Internalized shame scale: Professional manual. Menomonie, WI: Channel Press. Dunn, J., Bretherton, I., & Munn, P. (1987). Conversations about feeling states between mothers and their young children. Developmental Psychology, 23, 132–139. Erikson, E. H. (1950). Childhood and society. London: W. W. Norton. Fisher, K. W., Shaver, P. R., & Carnochan, P. (1990). How emotions develop and how they organize development. Cognition and Emotion, 4, 81–127. Fung, H. (1999). Becoming a moral child: The socialization of shame among young Chinese children. Ethos, 27, 180–209. Goffman, E. (1967). Interaction ritual. Chicago, IL: Aldine Publishing Company. Kauffman, J. (Ed.). (2014). The shame of death, grief, and trauma. New York, NY: Routledge. Kaufman, G. (1995). Shame: The power of caring. Boston, MA: Schenkman. Kaufman, G. (1996). The psychology of shame: Theory and treatment of shame-based syndromes (2nd ed.). New York, NY: Springer. Keltner, D., Young, R. C., & Buswell, B. N. (1997). Appeasement in human emotion, social practice and personality. Aggressive Behaviour, 23, 362–369. Kugler, K., & Jones, W. H. (1992). On conceptualizing and assessing guilt. Journal of Personality and Social Psychology, 62(2), 318–327. Lindsay-Hartz, J. (1984). Contrasting experiences of shame and guilt. American Behavioural Scientist, 27(6), 689–704. Lou, V. W. Q., & Chan, C. L. W. (2006). Walking tightrope: The loss of parents of children with cancer in Shanghai. In C. L. W. Chan & A. Y. M. Chow (Eds.), Death, dying and bereavement, A Hong Kong Chinese experience (pp. 241–250). Hong Kong: Hong Kong University Press. Nicols, M. (1992). No place to hide: Facing shame so we can find self-respect. New York: Simon & Schuster. Sandler, J., Holder, A., & Meers, D. (1963). The ego ideal and the ideal self. The Psychoanalytic Study of the Child, 18, 139–158. Scheff, T. J. (1997). Shame in social theory. In M. R. Lansky & A. P. Morrison (Eds.), The widening scope of shame (pp. 205–230). New York, NY: Routledge. Shaver, P. R., Wu, S., & Schwartz, J. C. (1992). Cross-cultural similarities and differences in emotion and its representation: A prototype approach. In M. S. Clark (Ed.), Review of personality and social psychology (Vol. 13, pp. 175–212). Newbury Park, CA: Sage. Stipek, D. (1998). Differences between Americans and Chinese in the circumstances evoking pride, shame and guilt. Journal of Cross-Cultural Psychology, 29, 616–629. Tangney, J. P. (1992). Situational determinants of shame and guilt in young adulthood. Personality and Social Psychology Bulletin, 18(2), 199–206. Tangney, J. P., Wagner, P. E., Hill-Barlow, D., Marschall, D. E., & Gramzow, R. (1996). Relation of shame and guilt to constructive versus destructive responses to anger across the lifespan. Journal of Personality and Social Psychology, 70(4), 797–809. doi:10.1037//0022-3514.70.4.797.

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Tomkins, S. S. (1963). Affect, imagery, consciousness: The negative affects (Vol. 2). New York, NY: Springer. Viken, A., Hassel, A. M., Rugset, A., Johansen, H. E., & Moen, T. (2010). A test of shame in outpatients with emotional disorder. Nordic Journal of Psychiatry, 64, 196–202. doi:10.3109/080394809033981.

3

Shame’s dualistic nature

Besides the hiddenness of shame, another reason why the methodical study of shame has been mostly neglected until recently is possibly because we have failed to fully understand the complex dual characteristics of the nature of shame. The preceding chapter dealt with the individual’s need to hide the shame for fear of its exposure. Yet there are times when it is important to reveal one’s shame due to our innate human need to belong and be included as part of a social group. As we have seen earlier, an external expression of shame can signal others our admission of having acted outside of social norms in order to remain connected with others. This paradox highlights one aspect of the dualistic nature of shame. Some other aspects of such dualism have also been alluded to in the last two chapters, but for comprehensiveness and clarity, the entire spectrum of the dualistic characteristics of shame is described here more fully.

Two foci Indeed, the focus on shame can be both individually and socially orientated at the same time. On the one hand, a person may want to be invisible to others in case there is a risk of exposure to shame. In that sense, it safeguards the boundaries of the self as in protecting our privacy or the public display of our nakedness. For example, after her miscarriage, Jo (P07) tried to minimise her exposure to shame by avoiding her mother because she thought it would be shameful to talk about the loss with her. She knew that her mother was eagerly looking forward to have a grandson from her while her younger sister has already given birth to a daughter. She lamented, “I let my mother down terribly”. Hence, with her mother, her focus was on avoiding the experience of her shame arising from her “failure”. On the other hand, one may also want to be visible and acceptable by others despite the shame. In contrast to her earlier lament, Jo claimed that in the last two months after her miscarriage, she attended three “full moons” (celebrations one month after birth) of the babies of her office colleagues, knowing full well that they would ask her about her miscarriage and she would experience shame while talking about it. Here, her focus was socially orientated despite her shame. All in all, the paradox of this focus on shame has to be delicately negotiated on a

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Understanding shame

daily basis depending on one’s confidence level and shame-proneness as well as the extent to which the person wants to remain connected with others. In the wider context, the personal and social focus on shame also depends on the general pervasiveness of this emotion in the primary cultures of the world. Haidt (2003) avers that although shame is a natural emotion in the make-up of all humans, it shows up less in Western cultures because the primary focus on shame there mostly constitutes an admission of a personal sense of wrongdoing or failure such as the violation of social norms. However, the primary focus of shame experiences in the Eastern cultures is based more on the individual’s social status and the need for appropriate expressions of shame in the presence of someone of higher standing. As a result, the expression of shame in the West, as a personal response, is a lot more muted as compared to that in the East where it is seen as an essential ingredient for social cohesion. Hence, Dellmann (2017) posits that although shame is experienced everywhere, it is said that in the West, it has more intrapersonal or psychological dimensions, while in the East, it has more interpersonal or social dimensions. Intrapersonal shame arises when one feels to have failed to live up to one’s values, experiencing lowered self-defined esteem, while interpersonal shame arises when one believes to have failed to live up to other people’s expectations, thus experiencing lowered social esteem. Indeed, intrapersonal shame is more private while interpersonal shame is more public.

Two functions Next, shame can function both adaptively and maladaptively. Shame in its normal and adaptive form functions effectively within a person who has a fair sense of security and adequacy. It is experienced on a daily basis as a natural response to any threat or violation of social, moral or cultural norms. For example, on the first day back at work after her miscarriage, Jo said that she had a brief chat with her office colleague who was five months pregnant like she was. Then she noticed her big tummy and the very sight of it triggered in her both shame and sadness. Immediately, she excused herself and went into the privacy of a toilet cubicle to cry her heart out. In this occasion, her shame prompted her to withdraw so that she was not overwhelmed by her sadness and caused a scene that would disrupt the social harmony of the office environment. Thus, her experience of shame in this instance is adaptive and socially befitting. Indeed, such experiences of shame are positive and constructive in that they remind us we are human, we all have weak moments or we make mistakes. But as human beings are inherently gregarious, shame is part of the family of emotions that helps us to adjust to the demands of belonging to a social group. A sense of shame alerts us when a social blunder or violation is incurred or about to be so. Since we want to be valued, respected and accepted by others despite our weaknesses or mistakes, the person can correct her behaviour and take remedial actions to reduce the risk of rejection and remain connected. Such shame is usually fleeting and transitory with no lasting effects on one’s identity. Hence,

Shame’s dualistic nature 21 the adaptive function of shame is constructive for one’s personal well-being and the good of society. Indeed, shame can teach us good and pro-social human virtues such as cooperation, empathy, compassion, modesty, humility and gratitude. Thus, shame also functions to motivate us towards personal growth as we continue to relate to others in a respectful manner. When shame is too harshly imposed or experienced at an intensity that is too overwhelming to be managed by an individual, it can turn acute (or chronic or toxic) to function maladaptively. For instance, Jo regretted that when her mother asked when she intended to conceive again, she felt so intensely shameful of her “failure” to give birth that she impulsively chased her out of her house and vowed never to talk to her again. Such intensified shame can in fact predispose a person towards self-blame and self-hate. In addition, further exposure with no successful attempts to repair and reconnect to others will often drive the person to try and avoid getting in touch with the painful inner state of shame by pushing it out of conscious awareness and internalizing it.

Two awareness The milder forms of shame dwell in conscious awareness. This comes by way of blushing, embarrassment, awkwardness, the lowering of one’s glaze, the slumping of the shoulders, increase in the heart rate and other physical sensations of shame. When experiencing such unpleasantness, the person will either withdraw from the scene or distance oneself from such sensations through projecting it out by labelling the situation with masked words such as embarrassing or feeling awkward. Fortunately, this form of adaptive shame is only fleeting and transitory. We already saw such shame at work in Jo on her first day back at work. Once again, when the shame is imposed too harshly or become too overwhelming or experienced repeatedly, the emotion can become acute. Over time, the shame can be denied, disapproved and disowned by pushing it out of conscious awareness, thus numbing and separating it from the original shaming event. But the shame memories are only psychologically pressed down and contained in the unconscious for the time being. At any moment, they can be triggered by subsequent shame experiences, which are identical or even distantly associated with the suppressed shame memories, thus intensifying the shame into a never-ending vicious spiral. When Jo was a child, her mother used to compare and shame her for not being as good or clever as her younger sister. After her sister got married and subsequently gave birth to a daughter, Jo was more eager to conceive. Although her mother already knew of her miscarriage, Jo was too ashamed to talk to her or her sister about it. Eventually, she ended up distancing herself from both of them. The psychological dynamics of shame underlying this whole situation is that her childhood’s acute shame had lied buried and unresolved in her unconscious. The shame experienced by her in her miscarriage triggered her childhood shame memories as another failure or being inadequate, thus intensifying her present shame to made her react impulsively to both of her family members.

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Understanding shame

Indeed, the pervasive nature of acute shame over time will result in its internalization, which acts to corrode one’s identity with a core belief that the self is inadequate or flawed, and hence unattractive or unacceptable to others. When this happens, the shame no longer needs to be triggered in the presence of others. Any change in the perception of self can activate the feelings of shame. The person then becomes shameful for being ashamed, and the cycle of shame is put in motion.

Two sources Just like the two awareness of shame described earlier, this emotion can be externally or internally generated. As external sources of shame, significant others, acquaintances, the public, institutions, culture and the media through their norms and expectations that come with potential to shame are in fact powerful regulators of social behaviour. Violations can be judged unkindly, and this is experienced more severely in shame-based societies. Even a momentary gaze from a disapproving significant other or a negative feedback in the social media can elicit shame to varying degrees. In closely knit communities or countries with a high level of national pride, people can even feel vicariously ashamed for the shameful acts committed by those around them. Such external sources of shame can act as a powerful force for garnishing social cohesiveness, but this can also be abused by those in power as a control mechanism. As stated earlier, harshly imposed, overwhelming or repeated experiences of shame turn it acute and when not resolved within, the shame gets internalized over time to become shame memories that corrode the person’s sense of self as defective. This is done through the core beliefs in the unconscious which constantly generate negative thoughts of shame and low self-worth. As a result, the person experiences shame anxiety and constantly anticipates shame generated from within even without any valid sources of external shame. In such a situation, there is an inner voice that indiscriminately shames the person for the slightest reasons through self-criticism, self-hatred and self-annihilation.

Two indicators There are two broad classes of clinically useful indicators of shame to help both the therapist and the client accurately perceive and identify the presence of shame. Unless we are very familiar with these indicators, shame can in fact surface like an elephant in the room and stare right at our faces without us recognizing it. Firstly, there are the physiological indicators which include facial signs such as the avoidance of eye contact, lowering of the head and blushing as stated earlier. There are also changes in posture and countenance such as the slumping of the shoulders with eyes staring at the floor, or an uneasiness that reflects a sense of embarrassment, awkwardness, frozenness, rapid heart rate or a need to withdraw. Secondly, there are the psychological indicators which the therapist has to discern and explore with the client before explaining to him that they are in fact

Shame’s dualistic nature 23 expressions of shame. When a client says he always feels like a fraud or an impostor, his shame is manifesting as diminished self-concept. There is this general sense of worthlessness, inferiority, inadequacy, defectiveness or emptiness. In short, the client feels unlovable as a person. Shame-bound people also frequently complain of feeling self-conscious and exposed to others as well as to the watchful eyes of the self. In interacting with others, such a person will be engaged with withdrawal, attackself, attack-other and avoidance type of defence strategies (Nathanson, 1993). Attack-other strategies will quickly surface and be noted when contemptuous responses are directed at the therapist even at the beginning of a therapy session. The other three strategies operate more subtly, but their effect is to neutralize the shame-threatening impact of others and distort the quality of interpersonal interactions. These strategies will be further discussed under Part 2 of this book.

Two states Lastly, shame exist in two states, either healthy or unhealthy. Chapter 9 will break down and name the components of healthy shame, while Chapter 10 will break down and name the components of unhealthy shame. Unhealthy shame operates not just to cause shamefulness but also shamelessness. This is because unhealthy shame can be disavowed to give rise to shamelessness. Disavowed shame is further discussed in Chapter 11.

Bibliography Bradshaw, J. (2011). Healing the shame that binds you. Deerfield Beach, FL: Health Communications Inc. Dearing, R. L. & Tangney, J. P. (Eds.) Shame in the therapy hour. Washington, DC: American Psychological Association. Dellmann, T. (2017). Are shame and self-esteem risk factors in prolonged grief after death of a spouse? Death Studies. Advance online publication. doi:10.1080/ 07481187.2017.1351501. Haidt, J. (2003). The moral emotions. In R. J. Davidson, K. R. Sherer, & H. H. Goldsmith (Eds.), Handbook of affective sciences (pp. 852–870). New York: Oxford University Press. Kaufman, G. (1996). The psychology of shame: Theory and treatment of shame-based syndromes (2nd ed.). New York, NY: Springer. Nathanson, D. L. (1993). About emotion. Psychiatric Annals, 23(10), 543–555. Sanderson, C. (2015). Counselling skills for working with shame. London, England: Jessica Kingsley Publishers.

4

Development stages of intensified shame

Now that we understand some aspects of the complex nature of shame, we want to further examine how it gets intensified from the early childhood days right through to adulthood. This chapter traces how normal shame which is at first healthy and adaptive develops to incorporate unhealthy and maladaptive components over the years.

Shame in early childhood An infant at birth already has a propensity to shame inbuilt in him. This view is somewhat different from what Lewis (1992) holds that the propensity to shame is developed over time during early childhood rather than present from birth. I believe that human beings are born with an inherent propensity to shame, but it is the external circumstances that first trigger the infant’s shame to be manifested as a shame experience. According to Erikson (1950), the first stage of a child’s development is forming a sense of trust, failing which mistrust will develop. When the primary caregiver (normally the mother) is lovingly attuned to the needs of the infant and meets those needs, the child gains trust, which is the source of his sense of security and adequacy. An attuned response to the need of what the infant expects is what Kohut (1971) calls as mirroring the self-object. A “good enough” response is all that is expected since no caregiver is perfect. As the trust grows, the emotional bond is strengthened between the child and the caregiver to accord the former more security and adequacy to risk venturing out and explore the world. This is the time when the infant needs to develop his own sense of self and learn personal boundaries through exploratory self-expression. It is usually explored under the watchful and protective eyes of the caregiver, but the issue is whether that person is serving as a secure base (Bowlby, 1969) to which the child returns without fearing any adverse repercussions, or she is someone who would thwart the freedom of his outward moves every now and then. Erikson postulated that the outcome of the second stage of the child’s psychosocial development (18 months to 3 years) is dependent on his experience with the primary caregiver in “the ratio of love and hate, cooperation and wilfulness, freedom of selfexpression and its suppression” (p. 228). If the ratio is positive, there is a sense of

Development stages of intensified shame 25 self-control, from where arises a lasting sense of ego of goodwill and pride. If the ratio is negative, there is a sense of loss of self-control and foreign overcontrol, from where arises a lasting sense of doubt and shame. Thus, when the infant is confident that there is love, cooperation and freedom for self-expression under the watchful protection of the caregiver, he is motivated to further explore without risking the withdrawal of the emotional bond by the adult. However, the infant must still know his limitations, as his new-found autonomy will often land him in moments of embarrassment such as falling down or shyness in the presence of strangers. The experience of such fleeting sense of normal shame is healthy as it is essential to signal to the infant that he is human and not omnipotent. On the other hand, if the toddler’s curiosity is met with hate, wilfulness and suppression from the primary caregiver, he will perceive these negative responses as mirroring back to him how bad he is, and he will feel ashamed of himself. At the same time, he will be fearful that the emotional bond he has with the caregiver will be broken since she is displeased with him. Such a rapture of the emotional bond is tantamount to abandoning him, and this is life-threatening to a helpless infant. The shaming experience can thus be very traumatic to him, and it gets deeply etched in his memories. Further similar external shaming incident can trigger off the unresolved shame of the old experience and set off a disproportionate intensity of shame in the child beyond the normal and healthy level to what is termed as acute (or chronic or toxic) shame which is maladaptive. As further shaming experiences take place, new verbal imprints and visual images of shame will be added to what is already there in the unconscious to form collages of shame memories. As these collages of shame gets bigger and deeper, the shame gets internalized. When shame is internalized, it no longer needs to be activated by what is external, but it can also be triggered internally through changes in the perceptions and thoughts of the person concerning himself. He will feel shameful for being ashamed of himself, and this will reinforce his need to withdraw from others in order to avoid the risk of more shame. In fact, the self can be so infected by shame that the person adopts a shame-bound identity with core beliefs that he is defective, unworthy and inadequate. Internalized shame is thus the most toxic component of shame.

Transgenerational shaming Unhealthy shame is often passed down from one generation to the next and so the transmission of shame is transgenerational (Sanderson, 2015). If the primary caregivers are shame-prone, they will model to the child their shame-based attributes and pass down their unhealthy shame through their negative responses to the child’s needs. This is seen in the case of Patty (first mentioned in Chapter 1 with obsessive-compulsive disorder) whose mother lived with much shame after marrying an irresponsible husband who did not provide for his family and abandoned them for many extensive periods of time without any trace of contact.

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Understanding shame

Her mother had often isolated herself from the neighbours and friends as she felt very shameful when they asked her on the whereabouts of her husband. Since baby Patty had the physical features of her father, her mother had often taken it hard on her because her looks would remind her of her husband and aroused deep anger in her. Through the mother’s harsh responses to the infant’s needs, often raising her voice on her, she had been modelling and passing down her unhealthy shame on Patty. When the child was about three years old, during one of her father’s brief stay at home, he went close to her and held her hands. Instead of feeling the fatherly love, Patty experienced his closeness as a man molesting her. This was because she was already predisposed to be shameful of her father with the unhealthy shame passed down by her mother. Indeed, the felt shame of being “molested” by her father was so traumatic to her that it was internalized, infecting her core identity as someone who is now “dirty”. Hence, Patty grew up constantly ashamed of her “dirtiness”. Whenever she uses the toilet or bathroom and touches her underwear, she would feel dirty and washes her hands repeatedly as a compulsive ritual to get rid of her “dirtiness”. But the psychological damage goes beyond her compulsive rituals. After she got married, if ever her husband raises his voice over her during the slightest marital conflict, she would be so overwhelmed by her shame that she is driven to become suicidal to escape the pain of it. No matter what her husband says, she will perceive him as running her down and shaming her because he is treating her as “dirt”! In fact, any raised voice from a significant other is sufficient to trigger off a disproportionate intensity of shame in Patty because right from the beginning, unhealthy shame has been passed down by her mother through her raised voice in harsh response to the infant’s needs. This is a typical vivid illustration of the crippling effect that unhealthy shame can have in a person’s well-being right through adulthood.

Other social settings of shaming Indeed, the family is the main setting where our core identity is first formed by the manner in which the infant since birth is cared for by the primary caregiver. Our core identity can be secured and adequate with a healthy sense of shame and self-esteem, or it can be insecure and inadequate with low self-esteem and a disposition towards unhealthy shame. Of the four shame-based cases illustrated in Chapter 1, two other persons are shame-bound due to the unhealthy shame directly passed down at home from their primary caregivers. Norman’s parents shamed him terribly for not doing as well as his younger sister in their studies. He grew up to be a wife-beater due to his high sense of inferiority and shame towards younger women. Alex was placed by his widowed mother under the care of a domestic maid who had often rejected and abandoned him. He was addicted to gambling as a substitute for his lack of quality relationships. It is a way for him to avoid intimacy and closeness due to his lack of relational worth. As the infant grows and attends play groups, school, sports or music lessons, religious classes and other activities, then enters into adulthood, comes out to

Development stages of intensified shame 27 work, marries and sets up his own family, each social system will contribute to the adverse shaming experiences of the person, which unless repaired and resolved, will add to the collages of shame that can get intensified and internalized. For instance, we see in Chapter 1 that Anne subsequently spiralled into severe depression while in University as a result of constant adverse shaming by her teachers back in school. In any setting, we can be insensitively teased by others for not performing to their expectations, ridiculed for our weaknesses, looks or neediness, humiliated for not knowing and so on. In fact, social researcher Brene Brown (2015) has differentiated the range of shaming triggers into 12 categories: appearance and body image; money and work; motherhood/fatherhood; family; parenting; mental and physical health; addiction; sex; aging; religion; surviving trauma and being stereotyped or labelled. In any of these categories, if a person’s sense of self is secure and adequate, the individual will have a healthy affect regulation system that helps one not to over-react to the many forms of humiliation or ridicule. However, if the person has past shame wounds from traumatic or repeated shame experiences both in the early childhood days or in later adulthood, and these shame wounds remain unresolved, even the slightest disapproval or disagreement, whether real or imagined, can trigger off the internalized shame to disproportionate intensities. Indeed, intense shame and internalized shame are related to each other bilaterally. When there is internalized shame due to past unresolved shame wounds, the person is predisposed to experiencing intensified shame since the slightest provocation can trigger off the shame memories. The shame is then experienced as acute and it adds to the collages of shame to a bigger and deeper pool of internalized shame memories, thus repeating the cycle of shame continuously and in greater intensity. The following Chapter 6 will examine empirically the bivariate relationships between how often we have been shamed in the past, the intensity of those shaming incidents and their effect on our present shame, as well as some other significant correlations of shame arising from my two-year study on the subject.

Bibliography Bowlby, J. (1969). Attachment and loss, volume 1: Attachment (2nd ed.). New York, NY: Basic Books. Bradshaw, J. (2011). Healing the shame that binds you. Deerfield Beach, FL: Health Communications Inc. Brown, B. (2015). Daring greatly: How the courage to be vulnerable transforms the way we live, love, parent, and lead. New York, NY: Gotham Books. Dearing, R. L. & Tangney, J. P. (Eds.). (2011). Shame in the therapy hour. Washington, DC: American Psychological Association. Erikson, E. H. (1950). Childhood and society. London, England: W. W. Norton. Kaufman, G. (1996). The psychology of shame: Theory and treatment of shame-based syndromes (2nd ed.). New York, NY: Springer.

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Kohut, H. (1971). The analysis of the self. New York, NY: International Universities Press. Lewis, H. B. (1992). Shame: The exposed self. New York, NY: Free Press. Sanderson, C. (2015). Counselling skills for working with shame. London, England: Jessica Kingsley Publishers.

5

My own struggles with shame

To further illustrate the developmental aspects of shame as discussed in Chapter 4, some of my personal struggles with shame are highlighted in this chapter. It tracks some of my own landmark shame situations from my childhood days as a child growing up into adulthood and elaborates on why as a professional psychotherapist, I took particular interest to specialize in grief therapy and attending to clients with mental health issues rooted in shame. This shows that our shame experiences can often shape who we are and what we do.

Growing up Unhealthy shame memories can breed in us not necessarily through the shameful, traumatic or abusive actions of other people but also through part of the product of the environment that we are in. For myself, it was the extreme poverty of the family that I was born into that filled me with shame in my growing years. I grew up in a traditional Chinese family in Malaysia (in South-East Asia) where my parents immigrated from China in the early 1920s. There was then a famine in mainland China. When I was five years old, my father suffered a severe stroke and he became incapacitated for the rest of his life. To keep the family going, my mother came out to work as a domestic maid, earning a meagre monthly income. In our poverty, we often lived in starvation due to the lack of food at home. Once a week, she would take home part of the food leftover by her employer for his dogs, and so I survived virtually fed by dog food! We suffered in silence as my mother in her traditional Chinese mindset did not want people to know about our difficult situation for fear of them looking down on us. Her traditional Chinese mindset has to be understood in the light of her values, ethics and morals, which are greatly influenced by Confucian philosophy, and to a lesser extent, the religious impact of Daoism and Buddhism. Indeed, the ideas and principles of Confucius are still very much part and parcel of Chinese culture and thinking even today, passed down from generation to generation over 2,500 years (Littlejohn, 2010). Confucian teachings on filial piety holds that failing to maintain the family together and keeping it in normal functioning is regarded as failure in one’s life (Chen, 2013; Dien, 1999). Indeed, we were

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Understanding shame

ashamed of our poverty, but we projected an image that we were managing our lives and family fairly well. Due to my shame, I grew up as a shy person. For instance, I was taught by my mother to talk only when asked to, since this was the behaviour expected of her working as a domestic maid in a Chinese family. When I was older, I realized that my shame was restrictive on the quality of my relationships with others, and I began to yearn to be more spontaneous, expressive and liberated as a person so that I could live a more fulfilling life. So, the type of shame that moulded my identity well into my adult years was not the result of any traumatic incidents of abuse or humiliation, but it was the constant reminder of the deprived condition that one lived in that generated the shame when compared to the abundant providence of other families. I remembered that when I was a young kid first time going into the house of a rich schoolmate, I was so appalled by the open display of wealth that I stole an ivory pendant which was lying around the living hall as though it was a rubbish item that no one cared about. For many years, I lived with the guilt of my theft until the day I confessed to the owner and returned what I have stolen from his house. It was the shame of my depravation that tempted me to steal against all my inner conscience.

Famous in school For my first day at primary school, my mother gave me a school bag stuffed with a type of fresh vegetables called “sang choy” in Cantonese language. The name sounded like being “alive”, and according to my mother’s superstitious beliefs, this would generate a positive omen to make me an active student good in my studies. It happened that the class teacher wanted to check with each student whether his parents had bought all the right textbooks required for the first school term. She eventually came to me, opened my school bag, and lo and behold, instead of some textbooks, she only saw vegetables! She laughed nonstop and the entire class also laughed till their jaws dropped. Except me! I was utterly embarrassed and dumbfounded! The shame was so terrifying that it affected all my future interactions with people. At that time, my mother also saw me growing tall faster at that stage of my life. In her simple wisdom, she made short pants for me that were long enough to cover my knees so that I could still wear them when I grew taller. So, I became famous on my first day at school, for the wrong and shameful reasons. I was known as the boy who brought to school raw vegetables instead of textbooks and the one who wore the very long short pants. From then on, I was determined not to be shamed again and so I rehearsed in my mind for hours what would be my best reaction or what would I say to rescue me from possible threats of shame in all my likely interactions with people. For example, I would fantasied myself greeting my teachers politely and saying something nice to them. I would also replay in my mind the scene of my teacher opening my school bag and imagine myself telling her that my mother had asked me to buy the vegetables on the way to school and that was why I had those

My own struggles with shame 31 vegetables with me. I supposed another reason I tried to anticipate as much as I could was because I wanted to overcome the shyness in me due to my family background and upbringing. But little did I know that I was also practising an elementary form of shame imagery reframing on myself. Nevertheless, what I did worked somewhat well for me as I eventually gained the reputation as one of the most polite and well-behaved boys in class. Outwardly, I appeared to be confident in talking and interacting with others but inside of me, I was all the time overly strung up and fearful of being shamed one more time. I knew that when I was not well-prepared for a situation, my index finger would start circling endlessly the shirt button next to my heart as a sign of my anxiety over any threat of shame. As a result, I think I completely missed out on the joy of growing up as a carefree child, beset by my shame and my continuous efforts to fend off any real or perceived threats of shame. It was only during my university days that I gained more confidence of myself and I tried to be less worried of what was ahead.

Shame in loss I graduated in business studies and eventually became a company CEO. When my first wife died suddenly of brain aneurysm at the age of 49, I was totally devastated. I then discovered that not many people understood the depth of my loss. Around the same time, a prominent Appeals Court judge in my country shot himself in the head on the third death anniversary of his late wife, after putting up his third fullpage newspaper insertion with beautiful poems about her each year. Reading between the lines, those poems were an open call for help. Yet, either nobody cared or nobody was competent enough to help. I did not want to end up like him and so I took up a counselling course in Australia to help myself. I soon learned that grief following the loss of a loved one is an entangled ball of emotions, which often includes shame in loss. Indeed, Gershen Kaufman (1996) states that in bereavement, “Although grief is obviously present, shame is no less so, only more hidden from view” (p. 53). He added, “shame may be experienced in the face of the death, that universal symbol of ultimate human powerlessness” (p. 55). Jeffrey Kauffman (2014) further opined, “Shame is a common and pervasive feature of the human response to death and other loss” (p. viii). From the aspect of trauma, Allen (2005) sees the loss of a loved one as often traumatic, and “traumatic events render you helpless – the core of shame” (p. 70). This is because trauma wounds the self, our sense of competence and the capacity for mastery. Yet, “the presence of shame as a significant factor in grief has been basically and widely unrecognized” (Kauffman, 2014, p. vii). For myself, I was particularly shameful of my total self-absorption in my grief and being so overpowered by it that I was unable to go to work for weeks. I saw it as a weakness that was not appropriate to project to my staff and clients as the company’s CEO. Indeed, Kauffman (2014) argued that every bond when broken triggers the vulnerability to shame. The other shame propensities listed by him include the shame of one’s own mortality, shame at having lost a loved one,

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Understanding shame

shame over not having loved well enough or been loved well enough, shame about one’s grief and its vulnerabilities, and more remarkably, shame of shame. Nevertheless, my familiarity with grief and shame in loss as a professional psychotherapist had helped me to empathize well with my clients following their bereavement and experiencing grief and shame at the same time. Likewise, I could also identify well with the shame in loss of the participants of my two-year study following their perinatal losses.

Graduate school My training in counselling led me not only to set up my own professional practice but also study further in psychology. In one of the graduate schools which I attended, it turned out that for my cohort, most of the students came from two nations, except for one each from India, Indonesia and Malaysia. The American course director frequently teased and made fun of the three of us as the “aliens”. In addition, being the oldest student in class, I was inevitably more alienated as the younger people formed their cliques, had their own activities and studied together. Indeed, one’s sense of belonging only grows through a positive identification with the rest of any group. When you felt like an outsider because of your age difference, made worse by the constant reinforcement from those in authority that reminded you of your identity as an alien because of your nationality, you become estranged from any sense of belonging despite putting up a friendly façade for the sake of social conformity. Kaufman (1996) described aptly about such a situation: “there is a lasting impression of one’s essential differentness from others, a difference that translates immediately into deficiency, into shame” (p. 274). Paradoxically, my past struggles with shame had not aggravated my experience of present shame while at graduate school but actually prepared me to weather through those four years fairly well. In hindsight, that is, after years of additional studies on shame and extensive professional experience in attending to cases rooted in shame, I discovered that I have done a few things right for myself since my childhood days concerning my approach to shame. For example, I was not afraid to talk about my shame, including writing about it as in this chapter. In fact, giving voice to my shame helps me to break the silence and secrecy that maintains and perpetuates it. The self-discovered early practice of shame imagery reframing on myself was spot-on. In addition, having the right attitudes and perspective in life over the area of shame is also very important. Indeed, all these factors had shaped my professional interest and approach towards addressing shame at its roots as given in Part 2 of this book.

Bibliography Allen, J. G. (2005). Coping with trauma, hope through understanding (2nd ed.). Washington, DC: American Psychiatric Publishing. Bradshaw, J. (2011). Healing the shame that binds you. Deerfield Beach, FL: Health Communications Inc.

My own struggles with shame 33 Chen, W. (2013). Filial Piety in Confucian family values. Journal of Changchun Education Institute, 29(3), 69–70. Dien, D. S. (1999). Chinese authority-directed orientation and Japanese peer-group orientation: Questioning the notion of collectivism. Review of General Psychology, 3(4), 372–385. doi:10.1037/1089-2680.3.4.372. Kauffman, J. (Ed.). (2014). The shame of death, grief, and trauma. New York, NY: Routledge. Kaufman, G. (1996). The psychology of shame: Theory and treatment of shame-based syndromes (2nd ed.). New York, NY: Springer. Littlejohn, R. L. (2010). Confucianism: An introduction. London, England: I. B. Tauris & Co. Sanderson, C. (2015). Counselling skills for working with shame. London, England: Jessica Kingsley Publishers.

6

Empirical findings of my study

Observing the direct correlation between past and present shame and between internalized and acute shame in the preceding two chapters, we now examine some significant empirical findings that can be deduced from my 2018–2019 study on shame in an Eastern context. The quantitative aspect of my two-year study involves examining primarily the statistical characteristics of shame and its relationship with social (in)validation and grief of 42 Malaysian women of Chinese background following their perinatal losses in the last three years or less. A summary of the study is presented as an Appendix to this book. The data collected from the three surveys are keyed into the Social Science (SPSS) software to generate the Pearson Product-Moment Correlation Coefficient (R) Output (two-tailed), which is then analysed for bivariate correlations. In statistical analysis, a significance level of 0.05 indicates a 5% risk of concluding that a difference exists when there is no actual difference. This is to say that an alpha (ρ) of 0.05 is commonly considered as a cutoff level for any significant impact. A ρ cut-off level of 0.01 is considered more significant in terms of impact.

Past and present shame Firstly, it is found that there is strong bivariate correlation between the number of past shame experiences and its impact (R = 0.84; ρ < 0.01). In other words, in line with what is said in the preceding chapters on the development of intensified shame, there is empirical evidence to show that the more times one is shamed, the greater is the impact of the past shame on the person. It means that the shame need not be very traumatic, but if it is experienced repeatedly, then its impact can also be damaging. For example, the mother of Norman, whom we featured in one of the four illustrative cases in Chapter 1, was shaming him repeatedly for not doing well compared to his younger sister in their studies. Each shaming incident by itself may not overly traumatic, but the repeated pattern of the shaming was accumulated over time to build up a high sense of inferiority and shame in him towards younger women. Secondly, there are significant bivariate correlations between one’s current intensity of shame and the number of past shame experiences (R = 0.37; ρ < 0.05), as well as the impact of past shame (R = 0.41; ρ < 0.01). So, when an individual is

Empirical findings of my study 35 now shamed by an incident, how intensely that person reacts to the shame depends on how often he has suffered similar shame experiences in the past and how traumatic is the shame to him. Hence, we see that Normal reacted intensely to his present shame at the slightest provocation by his wife, which he perceived as insulting or disrespecting him and started to abuse her physically. However, the statistical analysis also tell us that the intensity of any past shame impacts our current shame more than the number of past shame experiences. In other words, one intensely traumatic shame incident is enough to cause more damage than a series of repeated but milder experiences. In one of the four illustrative cases in Chapter 1, we are told that Patty perceived to be molested by her father only once, but the incident was so traumatic to her that she grew up ashamed of her “dirtiness”. Indeed, other studies have also shown that any significant and traumatic shame incidents in the past and especially those during childhood can often predispose a person to feel more shame than other people. For instance, Regencia (2008) showed that in an Asian country such as the Philippines, “the impact of shame in the person’s life is powerful” (p. 99), and her findings suggested that past trauma or abuse experiences and the resulting internalized shame could contribute to as much as 60% of the difficulty for single Filipino women to set interpersonal boundaries. There are indeed substantial literatures linking trauma and childhood abuse with shame (Feiring & Taska, 2005; Talbot, Talbot, & Tu, 2004; Wilson, Drozdek, & Turkovic, 2006). In addition, it is interesting to note that there is no significant correlation between shame and the age of the person. This means that unless our early and past shame wounds are ultimately addressed and resolved, those unhealthy shame memories stay with us throughout our life span to predispose us to intensive shame. This underscores the importance of addressing the unhealthy shame to set us free to live a life not beset by serious psychological difficulties with shame as the root cause.

Shame as mediator We now proceed to examine the statistical relationships of shame with social (in) validation and grief. Social invalidation may be taken as simply referring to the negative words and/or actions of other people in response to a given situation. Grief refers to the painful psychological consequences following a loss, but for the purpose of this study, it can be taken simply as the intensity of pain following a given shameful situation. Firstly, there is a very strong bivariate correlation between shame and social invalidation (R = 0.83; ρ < 0.01). This is to be expected as the negative responses of others towards whatever we are experiencing can arouse a certain level of shame in us. The more negative are their words or actions against us, the greater is our experienced shame. At the same time, what others say in negative response to us can also increase the intensity of our pain, measured in my study as corresponding to grief. Hence, there

36

Understanding shame

is a strong bivariate correlation between social invalidation and grief (R = 0.62; ρ < 0.01). In general terms, the more negative others talk about us, the worse we will feel. It is further noted that there is a strong correlation between shame and grief (R = 0.70; ρ < 0.01), meaning the greater is our shame, the more painful it is for us. In other words, the study provided the empirical evidence to show that there are strong bivariate correlations between any two constructs of shame, social invalidation and grief, each factor affecting the other in multiple ways. In terms of causal effect, is social invalidation and shame each affect our grief separately or is there a consequential process where one affects the other before grief is felt? By statistical analysis, we can show the empirical evidence that it is the social invalidation that activates our shame, which in turn makes us feel painful in our grief. For this purpose, the various combinations of shame, social (in)validation and grief are tested for mediation with regression analysis. Mediation is a hypothesized casual chain in which one variable affects a second variable that, in turn, affects a third variable. The intervening variable is the mediator. If a mediation effect exists, the effect of social invalidation on grief will weaken (represented by a reduction of the beta β coefficient) when shame is included in the regression. Indeed, shame (β = 0.60; ρ < 0.01) is found to be a strong mediator between social invalidation (with β reduced from 0.62 to 0.12) and grief, such that greater social invalidation predicts greater shame, which in turn predicts greater intensity of grief. This analysis has significant psychological implications. It shows that whatever happens to us externally, such as receiving a negative remark, it is our shame that is first triggered before we are grieved by that remark. This is a positive sign because whatever happens to us externally is beyond our control but with regard to our shame, we can do something with our affect regulation. If our affect regulation is functioning adaptively, then at most we will experience only a fleeting or transitory experience of healthy shame, prompting us to make any necessary amends. However, if our affect regulation is functioning maladaptively, the slightest negative remark will make us feel intensely shameful, prompting us to rely on habitual defence strategies to protect us from being grieved. Thus, the causal bivariate relationships between any two contructs of shame, social invalidation and grief predicts specifically through empirical evidence that for us to be badly affected by the negative remarks of others, we first need to check and address our predisposition to shame because it is the shame that will grieve us as a result of the social invalidation of others. In other words, if we are not overly sensitive to being shamed by the actions of others, then we will not overly suffer the painful consequences of it.

Self-esteem vs shame Self-esteem is a person’s sense of self-worth or how much we appreciate and like ourselves. Kernis (2003) defined self-esteem as an affective construct consisting

Empirical findings of my study 37 of self-related emotions tied to worthiness, value, likeableness and acceptance. Indeed, a realistic and positive view of oneself will motivate us to believe that we are able to accomplish our goals in life. Low self-esteem leaves us feeling defeated or even depressed. It can also lead one to make incorrect decisions or have destructive relationships. According to Yelsma Brown and Elison (2002), shame is manifested as an affect, whereas self-esteem is manifested as a more complex blend of affect and cognition. Putting it in another way, shame is the emotional indicator of self-esteem that arises when the more cognitive construct of self-esteem is threatened (Dellmann, 2017). Although shame and self-esteem are different constructs, they have been shown to have a strong correlation (Elison, Pulos, & Lennon, 2006). Hence, in psychology, self-esteem is often taken to be the antithesis of shame. The empirical evidence provided in this study indeed shows that there is a strong inverse bivariate correlation between shame and self-esteem (R = −0.44; ρ < 0.01), meaning that when shame in a person is high, the self-esteem will be low, and vice versa. Additionally, when our self-esteem is positive, we are generally not badly affected by the negative remarks of others about us; hence, there is a significant inverse bivariate correlation between self-esteem and social invalidation (R = −0.55; ρ < 0.01). Likewise, when our self-esteem is positive, we also do not end up feeling so bad about ourselves; hence, there is a significant inverse bivariate correlation between self-esteem and grief (R = −0.42; ρ < 0.01). Since shame and self-esteem are inversely related, it also means that if the intensity of shame in a person is high and the self-esteem is low, it is likewise beneficial to help someone address his maladaptive shame by improving his self-esteem. Hence, Part 2 of this book will discuss some other complementary antidotes to address unhealthy shame, which includes building up one’s self-esteem.

Education and shame It may be worthwhile to highlight that although we often expect that a higher education would enhance one’s self-esteem or mitigate one’s shame, the survey results in fact showed that there is no significant bivariate correlation between higher education and self-esteem or shame. This implies that in facing a shameful situation, a person’s higher level of education may do little to buffer her self-esteem nor ameliorate her shame. This can be explained psychologically by the fact that our shame experiences are much influenced by our past unresolved shame memories, which are implicit and right brain dominated. It is a common fact that the right brain is responsible for emotions, creativity and intuition, while the left brain is responsible for cognition, linguistics and logic (Corballis, 2014). Since education mainly involves cognitive processing and linguistics through the left brain, higher education therefore will not alter one’s propensity to shame.

38

Understanding shame

Bibliography Corballis, M. C. (2014). Left brain, right brain: Facts and fantasies. PLoS Biology, 12(1), e1001767. Dellmann, T. (2017). Are shame and self-esteem risk factors in prolonged grief after death of a spouse? Death Studies. Advance online publication. https://doi.org/10. 1080/07481187.2017.1351501. Elison, J., Pulos, S., & Lennon, R. (2006). Shame-focused coping: An empirical study of the compass of shame. Social Behaviour and Personality: An International Journal, 34(2), 161–168. doi:10.2224/sbp.2006.34.2.161. Feiring, C., & Taska, L. S. (2005). The persistence of shame following sexual abuse: A longitudinal look at risk and recovery. Child Maltreatment, 10(4), 337–349. Kernis, M. H. (2003). Toward a conceptualization of optimal self-esteem. Psychological Inquiry, 14(1), 1–26. doi:10.1207/s15327965pli1401_01. Regencia, C. T. (2008). Strengthening interpersonal boundaries of Filipino Evangelical single women. Manila: Asia Graduate School of Theology Philippines. Talbot, J. A., Talbot, N. L., & Tu, X. (2004). Shame-proneness as a diathesis for dissociation in women with histories of childhood sexual abuse. Journal of Traumatic Stress, 17(5), 445–448. doi:10.1023/b:jots.0000048959.29766.ae. Wilson, J. P., Drozdek, B., & Turkovic, S. (2006). Posttraumatic shame and guilt. Trauma, Violence & Abuse, 7(2), 122–141. Yelsma, P., Brown, N. M., & Elison, J. (2002). Shame-focused coping styles and their associations with self-esteem. Psychological Reports, 90(3c), 1179–1189.

7

Qualitative findings of my study

My two-year study also involves a qualitative aspect to examine some pertinent dynamics of shame in the Eastern context through interviewing several partici­ pants who took part in the quantitative surveys. The data gathered are analysed using the deductive thematic model of Braun and Clarke (2006).

Participants of the qualitative study The participants consisted of seven of the Malaysian women of Chinese back­ ground who had completed the quantitative surveys of this study following their perinatal losses. The seven persons ranged from 28 to 42 years, with a mean age of 33.6 years (SD = 5.0). Three of them had miscarriages, while the other four had suffered stillbirths. See Table 7.1 for a summary of the participants’ particulars and their type of loss.

Data collection and transcription One-time focused conversations were held with the seven participants who were willing to be interviewed after taking the quantitative surveys. Each conversation lasted between 60 and 90 minutes. Each focused conversation took place at a convenient location at the first meeting between the participant and the re­ searcher. The collaborative methodology adopted for collecting the information involved the researcher type-writing verbatim the conversation during the in­ terview and at the end of the session, the participant would read the transcrip­ tions, thus giving her the opportunity to correct, modify or add meaning to her story. Care was taken to ensure that there was a rigorous and thorough transcript to arrive at the verbatim account (Poland, 2002). However, repetitive stutters, fillers and minor silences as well as grammatical errors were subsequently edited for easier coding and analysis while ensuring that the transcript remained true to the original conversation. All identifying information was removed from the transcripts, and the participants were labelled from P01 to P42 only.

Age (yrs)

34 28 31 38 42

33 29

ID

P01 P02 P07 P22 P23

P24 P42

College College

1st degree 1st degree 1st degree Sec. School 1st degree

Education

Secretary Banker

Dentist Social worker Manager Administrator Housewife

Profession

Stillbirth Miscarriage

Miscarriage Miscarriage Stillbirth Stillbirth Stillbirth

Type of loss

Table 7.1 Description of the Seven Participants Interviewed

1st time 1st time

3rd time 1st time 2nd time 1st time 1st time

History of loss

Daughter, 3 yrs None None Daughter, 5 yrs Daughter, 8 yrs; Son, 3 yrs Son, 9 yrs None

Number of children

3 18

0 (ten days) 1 1 1 24

Time since loss (months)

40 Understanding shame

Qualitative findings of my study 41

Process precepts of data analysis Braun and Clarke (2006) provided some guidelines on deductive thematic analysis, which was adopted for the qualitative study. They emphasized that the following phases are not linear but recursive in that the researcher moves back and forth as required:

Phase 1: familiarizing with the data The researcher first immersed himself in the data by repeated and “active” reading to search for meanings and patterns.

Phase 2: generating initial codes This phase involved the initial coding of the data by identifying the basic seg­ ments that could be assessed in a meaningful way. According to the authors, coding can be done either manually or through a software program. Since the data collected from the seven one-time focused conversations were not volu­ minous, the transcript for the study was coded manually by type-writing the subject names on the text being analysed.

Phase 3: searching for themes This phase focused on sorting out the different codes into the overarching level of potential themes. A theme captures something important about the data re­ garding the research question and represents some level of patterned response or meaning within the data set. The “keyness” of a theme is not necessarily de­ pendent on quantifiable measures but also in terms of whether it captures something important regarding the overall research question. Hence, both prevalence and thematic importance were given equal attention in this study.

Phase 4: reviewing the themes This phase involved two levels of refining the themes. In Level 1, the collated extracts for each theme were reviewed to determine whether they formed a coherent pattern. In Level 2, the validity of the individual themes regarding the data set was reviewed to determine whether the candidate thematic map accurately reflected the meanings evident in the data set as a whole.

Phase 5: defining and naming themes Here, the themes were defined and refined through identifying the essence of what each theme was about and determining what aspect of the data each theme captured.

42

Understanding shame

Interpersonal consequences of perinatal loss

Intrapsychic consequences of perinatal loss Guilt

Sadness

Anger

Anxiety Self

Sadness

Shame

Withdrawal Social (in)validation Others

Figure 7.1 Final Thematic Map from One-time Focused Conversations.

Phase 6: producing the report Finally, the thematic analysis was written up to give a concise and coherent ac­ count of the data within and across the themes complete with some data extracts to demonstrate the prevalence of the themes.

Results of analysis As codes were sorted out into main and sub-themes to surface several candidate themes, two overarching themes emerged with coherent pattern, and with more reviewing and refining, a final thematic map is arrived at as shown in Figure 7.1. The two overarching themes referred to the intrapsychic and interpersonal consequences experienced by the participants following their perinatal losses. The intrapsychic consequences are mainly emotions and ruminations experienced within oneself. The interpersonal consequences result from their interactions with others, predisposed by their intrapsychic consequences.

Intrapsychic consequences The most common emotions and ruminations experienced and initially expressed by the participants as intrapsychic consequences of their perinatal losses are guilt, anger, anxiety and sadness. Chapter 2 has already covered the dynamics of these emotions illustrated by appropriate verbatims of what were said by the partici­ pants. We have also learned how these secondary emotions acted to keep the ensuing shame hidden. Guilt was mentioned by six of the seven participants. However, five out of the six who cited guilt reported that they had subsequently resolved their guilt at the time when they were interviewed. For example, Amy (P01) added, “Not so much guilt now as I found no significant basis to blame myself after checking out

Qualitative findings of my study 43 everything”. Similarly, Jo (P07) found comfort by saying, “But the “gynae” assured me there was nothing amiss in my pregnancy and so now I don’t feel guilty anymore”. The majority of the participants (five of seven participants) expressed anger either at themselves or at God for failing to bring their pregnancy to full term. The anger seems to come from a sense of unfairness incurred either on or by the mother/father or to the child. Likewise, all the five participants expressed not feeling any more anger when it was fully ventilated over time. For example, Emily (P23) who was angry at herself for not welcoming her third child when she was pregnant with him, subsequently relented, “Now, I just let go and don’t think of this anymore”. Similarly, Amy (P01) who initially blamed God for her mis­ carriage also said, “But as I talk to you now, that anger seems to have subsided”. Two other common emotions expressed by the majority of the participants are anxiety (four out of seven participants) and sadness (five out of seven partici­ pants). Anxiety refers to whether they will still give birth to children or what will happen in future, while sadness is often accompanied by crying. The majority of the participants expressed that they were still somewhat anxious over the pro­ spect of giving birth and still feeling sad over their loss, although not as bad as it was before. In hindsight, they tended to agree that in their frustration over what was beyond their control, they were in fact finding a convenient target of blame for the loss. Whether they blamed themselves and felt guilty or angry for what they had done or not done, or blamed God for being unfair to them, reality and common sense eventually overrode their need to hold someone responsible for the misfortune. They eventually accepted their losses as not within their control and so their guilt and anger began to subside. Over time, their anxiety and sadness also subsided as they return to their normal life. These secondary emotions which they readily admitted and expressed at the initial stage of their loss thus became less effective to cover their sense of shame. Therefore, when facing social invalidation, they would become more vulnerable to shame compared to right after the loss. In their favour, the quantitative survey revealed that Malaysian women of Chinese background have one to four or more persons close to them whom they can easily open up to (Mean = 2.4) following their perinatal losses. Processing their loss experience with people who are empathic to them would inevitably mitigate their shame and grief.

Interpersonal consequences Now let us consider some of the interpersonal dynamics following the perinatal losses. Table 7.2 presents the findings from the seven one-time focused conversations: When a participant stated that a person or group of persons that she interacted with following her perinatal loss are supportive, they are generally categorized in the study as socially validating. This applies to statements such as “My husband supports me fully and he gives me no pressure to give birth to another child”

44

Understanding shame

Table 7.2 Participants’ Interactions with Other People Participants:

P01

P02

P07

P22

P23

P24

P42

Others: Husband Mother Father Mother-in-law Father-in-law Siblings/Relatives Colleagues/Friends Validation Score Invalidation Score

1 0 0 2 0 1 2 33 57

0 1 1 2 0 ND 2 31 75

2 2 2 1 1 ND 1 33 66

1 1 1 1 1 1 1 37 30

0 0 0 0 0 ND 1 32 51

0 D/O D/O D/O D/O 0 0 36 33

0 1 0 1 0 2 2 33 38

Keys: 0 = No reactions; 1 = Supportive/Validating; 2 = Unsupportive/Invalidating; D/O = Deceased or Overseas; ND = No data.

(P01) or “My mother is supportive as she had a miscarriage before. She told me it is not my fault” (P02). Concerning social invalidation, there was generally no mention of any out­ wardly negative or hostile words spoken by others over their losses in all the onetime focused conversations. However, some words of concern, probably said out of good intent or without any ill-motive, could be perceived as unsupportive and socially invalidating. For example, Liza (P02) said: My mother-in-law was very sad. She was looking forward to her first grandchild. She was saying that she heard there are some Chinese herbs that can facilitate pregnancy and she wants to prepare it for me. I feel pressured, like (she was) hinting the question when you are going to get pregnant again. Liza also said, “My church members often bombard us with the question, ‘When is the next pregnancy coming?’ Or they ask, ‘Why not go and see a doctor to check if there is something wrong with you?’ It can become quite accusing”. In her case, both her mother-in-law and friends are categorized as socially in­ validating. This is reflected in her social invalidation score of 75 which is far above the mid-score of 60. In the transcripts, there is a separate category of interactions coded as “No reaction”. This applies to situations where it is not clear whether the other person is supportive or unsupportive of the participant as that person did not express any concern or otherwise to her over her loss. For example, Jo (P07) said: My husband saw me cried so much and for so long, he did not want to talk about it anymore. When the foetus came out, he took it for burial at the hospital mortuary. For my closure, I asked him to take me to the spot where

Qualitative findings of my study 45 she was buried, but he refused to do it. He just wanted to put the loss behind it and have nothing to do with it anymore. Other cases which are classified as “No reaction” include the following remarks: “My husband was then busy with a big project and he was not there with me emotionally” (Tricia, P42), and “I don’t usually talk with my father-in-law, much so with regards to the miscarriage” (Amy, P01). In addition, the participant’s parents or in-laws might be deceased or they might be overseas and seldom communicated with her. Under these circum­ stances, they are coded as Deceased or Overseas. If nothing was mentioned about certain people, they are coded as No Data.

Interpersonal findings First of all, it is noted that most of the Malaysian husbands of Chinese background generally expressed little or no expressed reactions following a perinatal loss. Of the men close to the participants, four out of the seven husbands were in this category while three out of seven fathers and four out of seven fathers-in-law were also in this category. Only two husbands were said to be supportive whereas one was perceived to be unsupportive. No clear-cut explanations for this trend can be deduced from the transcripts. However, the remark of Amy (P01) that, “My father-in-law is the Chinaman type, a man of few words, emotionless” may be indicative that this is because Chinese men are not very expressive of their feelings. On the other hand, as far as it concerned the bereaved mother, no reaction from their significant others might be perceived as social invalidation. This is particularly evident in the case of Emily (P23). She said the following concerning her husband: “Surprisingly, my husband did not say anything at all, even at the hospital when he stayed the night with me. Till now, he did not mention about the loss at all”. From the summary in Table 7.2, it is noted that all the people she interacted with had expressed no reaction over her loss except for her colleagues and friends who were socially validating, but she had a rather high social in­ validation score of 51. Indeed, no reaction can likely be perceived by the parti­ cipants as a form of disenfranchisement. Disenfranchisement occurs when a bereaved person’s grief is unrecognized or unacknowledged by the people around them because the loss experience, expression and adaptation of grief is outside of the grieving rules (Doka, 1989, 2002). Of the women close to the participants, mothers and mothers-in-laws were more socially validating when they themselves had experienced a perinatal loss before (P02’s mother; P42’s mother-in-law), but they were perceived by the participants to be more socially invalidating when they were longing to have grandchildren and thus disappointed over the perinatal loss (P01’s mother-inlaw; P02’s mother-in-law). When the mother or mother-in-law is invalidating, usually the father or father-in-law is also invaliding (P07’s father), or else, have no reaction (P01’s father-in-law, P02’s father-in-law). Likewise, when the mo­ ther or mother-in-law is validating, the father or father-in-law is also validating

46

Understanding shame

(P02’s father, P07’s father-in-law, P22’s father and father-in-law), or else, have no reaction (P42’s father and father-in-law). As regards to the participants’ in­ teractions with their siblings/relatives and colleagues/friends, no specific trends are detected from the transcripts. Secondly, the quantitative analysis of Chapter 6 suggested that there are strong bivariate correlations between any two constructs of shame, social (in)validation and grief, with shame/self-esteem as the mediators. The qualitative experiences of the participants indicated this to be so. For example, Amy (P01) stated, “My mother-in-law asked me”, “What went wrong?” I said I don’t really know. I felt ashamed and then I said, “I am sorry that I disappointed you”. “After that I felt very bad for some time and tried not to talk to her anything about the mis­ carriage”. The sequence showed that there was an initial social invalidation from her mother-in-law and this triggered more shame in her. Her grief then got more intense, thus suggesting that shame is the mediator between social invalidation and grief. Likewise, social invalidation through disenfranchisement will affect the grief through shame in loss. Thirdly, Nathanson (1993) described the Compass of Shame to represent four typical sets of affect management scripts to defend against the painful experience of shame. The strategies and techniques are (a) withdrawal, (b) attack-self, (c) attack-other and (d) avoidance. They govern the feelings, cognitions and be­ haviours that constitute the reactive phase of the shame experience. Withdrawal refers to the physiological actions of shame affect such as hiding, acting shy, running away and growing silent. Indeed, the typical strategy adopted by Malaysian women of Chinese background to defend against public exposure to shame following their perinatal loss is withdrawal (four out of seven participants). For example, Amy (P01) remarked: I don’t want to talk with my mother-in-law about my miscarriage. I am afraid that she might say something to blame me for it. She expects to have more than one grandchild from us. She felt very sad. I am kind of shy talking with her about my miscarriage. Likewise, Tricia (P42) also stated, “I just ignored the sarcastic remarks of my office colleagues and tried not to come face-to-face with them or talk to them at all except through email”. Fourthly, when a coping strategy such as withdrawal fails and there is some form of social invalidation from other people, the person will likely experience an external form of public shame we called disgrace. According to Gilbert (1997), disgrace is a public exposure to negative evaluation by others due to one’s weakness, inferiority, incompetence or social transgression, whether real or perceived. In Chapter 3, Jo (P07) had earlier related her incident: “I had a brief talk with my colleague. When I noticed her pregnant tummy, that sight triggered off both shame and sadness in me. I excused myself and went to the toilet to cry”. In such a situation, Jo felt disgrace because she perceived herself to be inferior to her colleague as a result of her stillbirth.

Qualitative findings of my study 47 To reiterate, disgrace is a public shame because for Chinese women, the cultural backdrop is influenced by Confucian tradition which holds that children are a symbol of blessing and family continuity (Wu, as quoted by Lou & Chan, 2006), and so losses through perinatal deaths are shameful for the mother for bringing shame to the family name in not fulfilling her expected role and duty to bear children. No outright words of social invalidation may be spoken, as illustrated in following statement of Liza (P02): Some friends asked me, “What’s wrong with you?” like I had some form of failure. Shame and disgrace were spot on. Others around me advised me to eat better, as though I am a weaker person now. They also say, “You have to care of yourself better” as though there is something wrong with me. I am not feeling sick but I am no longer the same as before. People don’t really care how I am feeling. They mostly ask how am I physically, but not how am I emotionally. Although no outright negative words may be spoken, the effect on disgrace is the same because there is also a certain external factor called stigma with regard to perinatal losses in Chinese culture. According to Crandall, Eshleman, and O’Brien (2002), stigma is a social construction framed by cultural norms, values and perspectives involving a de­ viance from those standards or public expectations. Stigmatization is putting a negative social marker on the person that he or she should be ashamed and socially excluded. Traditionally, there is deeper level of stigma concerning peri­ natal losses in that the Chinese expect women to give birth to a male child. Tong (2012) stated: For the Chinese, the birthing of a male child is an act of filial piety … a male child, whose responsibility is to perpetuate the spread of the family name and see to the continued care of the family ancestral altar. (p. 67) However, at least two participants had played down the prevalence of the malechild stigma. Amy (P01) said: I know my mother-in-law wants to have grandchildren, although not necessarily a boy. Yes, I remember at one time she commented why one family we know is still unhappy after they have two daughters. But we are living in a modern era and our society is modern. I reflected on her comment and I eventually concluded that my mother-in-law is not particular that we must bear a grandson for her. Likewise, Jo (P07) said, “My mother knew the baby is a girl and she’s not particular that we must have a son”. Thus, it appears that the stigma on Malaysian wives of Chinese background for not bearing a male child is not so prevalent, but the stigma on non-childbearing still exist in the cultural mindsets of the Malaysian Chinese, particularly amongst the older generations.

48

Understanding shame

With regard to the stigma on non-childbearing, no actual stigmatizing words need to be spoken, but the mere awareness of it is enough to bring public disgrace to a Malaysian woman of Chinese background experiencing a perinatal loss. This is a case in point for social constructionism epistemology which advocates that if descriptive meaning is governed by conventions, then judgement about the truth or falsity of descriptions are made by reference to the conventions rather than the observable features of the world (Gergen, 2009). Public shame following perinatal loss among Malaysian Chinese is due to our awareness of the stigma derived from prevailing convention that it is a cultural derogation, even though the bereaved mother may not have heard any words outwardly spoken as a social invalidation by the people in our midst.

Bibliography Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77–101. Crandall, C. S., Eshleman, A., & O’Brien, L. (2002). Social norms and the expression and suppression of prejudice: The struggle for internalization. Journal of Personality and Social Psychology, 82(3), 359–378. Doka, K. J. (Ed.). (1989). Disenfranchised grief: Recognizing hidden sorrow. Lexington, MA: Lexington. Doka, K. J. (Ed.). (2002). Disenfranchised grief, new directions, challenges, and strategies for practice. Champaign, IL: Research Press Publishers. Gilbert, P. (1997). The evolution of social attractiveness and its role in shame, hu­ miliation, guilt and therapy. British Journal of Medical Psychology, 70(2), 113–147. Lou, V. W. Q., & Chan, C. L. W. (2006). Walking tightrope: The loss of parents of children with cancer in Shanghai. In C. L. W. Chan & A. Y. M. Chow (Eds.), Death, dying and bereavement, A Hong Kong Chinese experience (pp. 241–250). Hong Kong: Hong Kong University Press. Nathanson, D. L. (1993). About emotion. Psychiatric Annals, 23(10), 543–555. Poland, B. D. (2002). Transcription quality. In J. F. Gabrium & J. A. Holstein (Eds.), Handbook of interview research: context and method (pp. 629–649). Thousand Oaks, CA: Sage Publications. Tong, C.-K. (2012). Chinese death rituals in Singapore. New York, NY: Routledge Curzon.

8

East-West distinctives

Now that we are more clear about the dynamics of shame in the Eastern context from my quantitative and qualitative studies, we are in a better position to examine the East-West distinctives on shame. Most psychological work on shame are written from the Western perspective, but there are differing perceptions and expressions of shame arising from the fundamental differences in the primary cultures between East and West. It has been mentioned from the beginning that traditional Western culture is more individualistic where the people are particularly self-reliant and so they prioritise competition and personal achievements. Traditional Eastern culture is more collectivistic, and people in the East are more interdependent, placing greater value on cooperation and interpersonal relationships. As a result, Westerners uses more cause-and-effect thinking, while Easterners adopt more group-oriented thinking.

Shame in Asia Indeed, among the world’s primary cultures, shame is said to be most prominent in Asia, the largest of the earth’s five continents and holding around 60% of the global population. Asia represents much of what is often referred to as the East. In their widely used and critically acclaimed text on multicultural counselling, Counselling the Culturally Diverse: Theory and Practice, Sue and Sue (2008) affirm that Asian cultures are mostly shame-based. The authors posit that traditional Asian values tend to celebrate family and community above the individual. Adapting to the needs of others and adherence to social norms are important for Asian people to protect their “face value” and maintain interpersonal harmony. Asian people are hence viewed as more emotionally restrained, interpersonally sensitive and respectful to those who are older (Sue & Sue, 2008; Triandis, 1995). Although most Asian people are now modernized and more westernized, they still construct their worldviews and society around the pivotal values of honour and shame. Their behaviours are influenced by concern for maintaining a positive reputation and harmonious relationships in the community (Li, Wang, & Fischer 2004; Sue & Sue, 2008). The Japanese, for example, are systematically socialized to identify totally with their community (Kaufman, 1996). Identification with the

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community will influence everything in their culture, including how shame is experienced. To feel shame is to expose both the self and the community simultaneously, and hence, shame should be avoided completely. So, shame in Asia involves more interpersonal dynamics, whereas in the West, it is more intrapersonal. Additionally, shame in Asia is not a simple, unitary feeling, thought or experience, but instead, it is a mixture of factors which vary from culture to culture, because cultures create, support, reinforce and define different feelings, awareness, wants, values and beliefs (Rosenblatt, 2014). Rosenblatt argues that we cannot simply translate the English language term of shame into another language without losing its distinctive cultural meaning. For example, Heider (1991) found that in three cultures in Indonesia, the finely differentiated aspects of shame do not seem to exist in English-speaking culture. Taking another example in the East, Tomas Andres (as cited by C. T. Regencia, 2008, in her work on interpersonal boundaries of Filipino Evangelical single women) opines that the word hiya, the Filipino term roughly translated in English as shame, is “defined in a literal sense as shy, timid, sensitive, rather than being ashamed” (p. 93). Likewise, there are additional terms also in the Tagalog language of the Philippines that can be translated into the English word for shame, but the metaphoric roots are rather foreign to English speakers, such as “debt of the inner being” (Palmer, Bennett, & Stacy, as cited by Rosenblatt, 2014). Hence, Rosenblatt avers that there are not many languages and cultures in which there is a term for shame precisely what it means in English.

Illustration of Chinese cultural impact on shame Among the Asians, the Chinese are particularly known for their “face-saving” shame orientation (Dunn, Bretherton, & Munn, 1987; Fisher, Shaver, & Carnochan, 1990; Fung, 1999; Shaver, Wu, & Schwartz, 1992; Stipek, 1998). Li Wang and Fischer (2004) posited that this is due to, firstly, the fact that “face” for the Chinese is a core notion of shame based on features such as anxiety about or threat of the loss of face and face-related feeling states when shame is actually experienced. Secondly, since the Chinese concept of shame is also closely related to moral concerns, there are strong shame-related responses to those who do not show a sense of shame for their shameful acts. The said authors noted that face-related concerns are self-focused, while shame-induced reactions are directed at others. Highlighted later is one distinctive Chinese cultural impact on shame to illustrate their extra sensitivity to shame as compared to the Westerners. I have read a popular self-help book entitled Empty Arms, Hope and Support for Those Who Have Suffered a Miscarriage, Stillbirth, or Tubal Pregnancy written by a Western bestselling author named Pam Vredevelt in 1994, herself a licensed professional counsellor, detailing her personal experience after suffering a miscarriage. She wrote about her struggles with a host of emotions, but in her book, she had hardly mentioned anything on shame, as though it is a non-issue in her perinatal loss. In another example, Carolan and Wright (2017) carried out a study on how a group of Western women perceive and describe their experience of miscarriage

East-West distinctives 51 from the cultural, social, relational, individual and temporal contexts. They arrived at two major conclusions. Firstly, the ambiguity of loss with miscarriage adds to the disenfranchisement of the grief experience. Secondly, in their search for meaning, participants question themselves on the why’s and how’s of the loss alongside with questions regarding the possible prevention of such a loss. Again, shame is not mentioned as an issue in their struggles. This is different in the Eastern context because there is often an issue of shame involved following a perinatal loss in their “face-saving” cultures. The shame usually revolves around why the mother fails to carry the baby to full term, while other women have succeeded. Lou and Chan (2006) stated, “According to Confucian tradition, a child in a Chinese family is not only an individual but is also a symbol of family continuity” (p. 242). Hence, losses through perinatal deaths are shameful for the mother for bringing shame to the family name in not fulfilling her expected role and duty. In fact, on the wedding day itself, the bride will wear a red gown embroidered with a phoenix to symbolize longevity and fertility (Tong, 2012). The wishes of the parents from both families of origin are that she will “bear many children” (p. 62). Actually, these wishes go beyond just giving birth to many children. Tong (2012) continues: For the Chinese, the birthing of a male child is an act of filial piety … a male child, whose responsibility is to perpetuate the spread of the family name and see to the continued care of the family ancestral altar … right up to today, it is also common for men to take multiple wives or mistresses should their wives not give birth to a male child. (p. 67) Therefore, it is shameful for a bereaved mother not to bring her foetus to full term, particularly in giving birth to male progeny, when other women have succeeded. The aforementioned example illustrates the role of culture in defining the different perceptions and expressions of shame between East and West in perinatal losses. The distinctions are invariably found in every facet of life where differences exist in the primary cultures of the world. Indeed, anthropologist Richard Shweder (2003) believes that despite the invariant nature of shame anywhere in the world, there are diverse ways of defining, experiencing, recognizing and communicating it.

Guilt vs shame Another East-West difference on shame that merits further elaboration is the distinction that the West is more guilt-based, while the East is more shamebased. It is said that Westerners place greater emphasis on personal guilt, legal innocence and retributive justice than on shame (Nida, 1954, Li, Wang, & Fischer, 2004; Muller, 2001). As stated in Chapter 1, what happened in the West was partly due to the fact that at the beginning years of modern psychology in the

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West in the 1900s, Sigmund Freud, who was then the prime mover of this new discipline, saw shame in relation to genital visibility, and hence shame received comparatively little attention, while the emphasis was on guilt. As a result, the situation in the West was such that Erikson (1950) aptly stated about shame being an emotion insufficiently studied because it was so easily absorbed by guilt. Notwithstanding, Western psychological literature went at length to differentiate between what is guilt and shame. Although both emotional states pertain to conforming to social rules and upholding the moral order (Orth, Berking, & Burkhardt, 2006), Haidt (2003) views shame as a feeling that the core self is bad, whereas guilt is a feeling that specific actions are bad. On the other hand, Allen (2005) states that “shame is a feeling of pervasive defectiveness, whereas guilt feelings stem from specific actions that are hurtful to others” (p. 70). In other words, shame involves a negative evaluation of the self, whereas guilt involves a negative evaluation of a specific behaviour (Lewis, 1971; Orth et al., 2006; Piers & Singer, 1953). Indeed, Nussbaum (2001) believes that shame tends to be more destructive than guilt because the former relates to a more pervasive sense of badness. In the East, however, the situation seems to be in reverse as though guilt is absorbed into shame. Initially, Fisher and Tangney (1995) aver that the distinction between guilt and shame in the East is less clear than that in the West. Li (2002) then made it clearer by stating that guilt and shame are overlapping and sometimes barely differentiated. Li, Wang and Fischer (2004) subsequently studied Chinese shame concepts in terms of meaning, experiences, reaction tendencies and social ramifications. In collecting data on the Chinese terms for shame, they discovered that “many guilt terms also entered our pool (of shame terms) because subjects (their study participants) either nominated or rated them as highly shame-related” (p. 787), indicating the absorption of guilt into shame. Thus, historical and cultural factors altogether subsume between guilt and shame one into the other but in reverse order between East and West. However, this is not to suggest that the cultures of the West emphasize totally on guilt only, nor those of the East focus on shame only (Peristiany & Pitt-Rivers, 1992). Indeed, Kaufman (1996) highlighted that the dynamics of shame can be seen in every culture, though they are patterned differently and to varying degrees. According to him, the West also has a shame-based culture, but there, shame remains hidden as the taboo on it is so strict that the people behave as if shame does not exist.

Mundane with same dynamics at work At the time of writing, I came across a mundane incident which somewhat serves to summarise the distinctions described previously. I live in the East and a Western lady came to visit my city. She was driving a rented car and was having difficulty to reverse-park her big car into a parking lot. After trying for a few times, she was holding up a long line of traffic behind her along a narrow and busy street and someone sounded his car horn. I happened to be in front of the

East-West distinctives 53 queue and I merely shook my head at her. Then she started to gesture furiously at me to show her displeasure over my impatience. To her Western mindset, she has the individual right to park her car properly and we have no right to be impatient to her. To my Eastern mindset, she is causing inconvenience to the community. So, she is expected to feel ashamed of her incompetency and ought to be apologetic towards those affected by her. The dynamics of this situation was that she was using more cause-and-effect thinking, while I was adopting a more group-oriented thinking. A while later, she saw me having my coffee and came to me complaining loudly of my impatience. I explained to her that in the West where society is more individualistic, she can insist on her individual rights, but in the East where society is more collectivistic, we generally put community well-being above that of the individual. Being so, if she had just waived apologetically to us, we would have been more gracious to give her the time to park properly. She was convicted by her guilt, softened her voice and feeling a little shameful, she withdrew from me. Although such a daily happening may not be of any significance to most people, the illustration nevertheless portrays another aspect of the dynamics of shame at work between East and West. For the Westerner, the second nature response is more intrapersonal, for she was first convicted by her guilt before she felt shame. This is because shame is more absorbed into guilt in the West. For the Easterner, the expectations are more interpersonal where one responds to shame on a collective basis as a second nature, probably mixed with a tinge of guilt at the same time.

Bibliography Allen, J. G. (2005). Coping with trauma, hope through understanding (2nd ed.). Washington, DC: American Psychiatric Publishing. Carolan, M., & Wright, R. J. (2017). Miscarriage at advanced maternal age and the search for meaning. Death Studies, 41(3), 144–153. Dearing, R. L., & Tangney, J. P. (2014). Introduction: Putting shame in context. In R. L. Dearing & J. P. Tangney (Eds.), Shame in the therapy hour (pp. 3–19). Washington, DC: American Psychological Association. Dunn, J., Bretherton, I., & Munn, P. (1987). Conversations about feeling states between mothers and their young children. Developmental Psychology, 23, 132–139. Erikson, E. H. (1950). Childhood and society. London, England: W. W. Norton. Fisher, K. W., & Tangney, J. P. (1995). Self-conscious emotions and the affect revolution: Framework and overview. In J. P. Tangney & K. W. Fisher (Eds.), Selfconscious emotions: The psychology of shame, guilt, embarrassment, and pride (pp. 3–22). New York, NY: Guilford Press. Fisher, K. W., Shaver, P. R., & Carnochan, P. (1990). How emotions develop and how they organize development. Cognition and Emotion, 4, 81–127. Fung, H. (1999). Becoming a moral child: The socialization of shame among young Chinese children. Ethos, 27, 180–209.

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Haidt, J. (2003). The moral emotions. In R. J. Davidson, K. R. Sherer & H. H. Goldsmith (Eds.), Handbook of affective sciences (pp. 852–870). New York, NY: Oxford University Press. Heider, K. (1991). Landscapes of emotion: Mapping three cultures of emotion in Indonesia. New York, NY: Cambridge University Press. Kaufman, G. (1996). The psychology of shame: Theory and treatment of shame-based syndromes (2nd ed.). New York, NY: Springer. Lewis, H. B. (1971). Shame and guilt in neurosis. New York, NY: International University Press. Li, J. (2002). A cultural model of learning: Chinese “heart and mind for wanting to learn.” Journal of Cross-Cultural Psychology, 33, 248–269. Li, J., Wang, L., & Fischer, K. W. (2004). The organization of Chinese shame concepts. Cognition and Emotion, 18(6), 767–797. Lou, V. W. Q., & Chan, C. L. W. (2006). Walking tightrope: The loss of parents of children with cancer in Shanghai. In C. L. W. Chan & A. Y. M. Chow (Eds.), Death, dying and bereavement, A Hong Kong Chinese experience (pp. 241–250). Hong Kong: Hong Kong University Press. Muller, R. (2001). Honor and shame: Unlocking the door. Philadelphia, PA: Xlibris. Nida, E. (1954). Customsand cultures. New York, NY: Harper. Nussbaum, M. C. (2001). Upheavals of thought: The intelligence of the emotions. Cambridge, England: Cambridge University Press. Orth, U., Berking, M., & Burkhardt, S. (2006). Self-conscious emotions and depression: Rumination explains why shame but not guilt is maladaptive. Personality and Social Psychology Bulletin, 32(12), 1608–1619. doi:10.1177/ 0146167206292958. Peristiany, J. G., & Pitt-Rivers, J. (1992). Honour and grace in anthropology. Cambridge, England: Cambridge University Press. Piers, G., & Singer, M. (1953). Shame and guilt. Springfield, IL: Thomas. Regencia, C. T. (2008). Strengthening interpersonal boundaries of Filipino Evangelical single women. Manila: Asia Graduate School of Theology Philippines. Rosenblatt, P. C. (2014). Shame and death in cultural context. In J. Kauffman (Ed.), The shame of death, grief, and trauma (pp. 113–137). New York, NY: Routledge. Shaver, P. R., Wu, S., & Schwartz, J. C. (1992). Cross-cultural similarities and differences in emotion and its representation: A prototype approach. In M. S. Clark (Ed.), Review of personality and social psychology (Vol. 13, pp. 175–212). Newbury Park, CA: Sage. Shweder, R. A. (2003). Toward a deep cultural psychology of shame. Social Research, 70, 1109–1130. Stipek, D. (1998). Differences between Americans and Chinese in the circumstances evoking pride, shame and guilt. Journal of Cross-Cultural Psychology, 29, 616–629. Sue, D. W., & Sue, D. (2008). Counselling the culturally diverse: Theory and practice (5th ed.). New York, NY: Wiley. Tong, C.-K. (2012). Chinese death rituals in Singapore. New York, NY: Routledge Curzon. Triandis, H. C. (1995). Individualism and collectivism. Boulder, CO: Westview. Vredevelt, P. (1994). Empty arms, hope and support for those who have suffered a miscarriage, stillbirth, or tubal pregnancy. Colorado Springs, CO: Multnomah Books.

9

Healthy shame

Until now, we have covered the hiddenness of shame, its dualistic characteristics and developmental features and examined some of its quantitative and qualitative dynamics in a study from an Eastern context held within a backdrop of shame’s East-West distinctiveness. The objective is to provide us with a broad understanding of this complex emotion. In the rest of Part 1, we will look into the psychological construct of shame by identifying and naming the basic components that constitute the entire shame continuum so that we will have a solid basis to learn how to address shame in a more effective way. It has been emphasized earlier that not all shame is maladaptive or harmful when we experience it. Inherent within us is a natural capacity to experience healthy shame as one of our primary emotions. Healthy shame guides our social behaviour, thus facilitating societal cohesion. This can lead us to develop more empathy and compassion for others. Dearing and Tangney (2014) broadly put healthy shame as a feature of in-the-moment shame and unhealthy shame as shame-proneness. In this chapter, healthy or adaptive shame is classified into two basic components: anticipatory and vicarious. The following chapter will cover the basic components of unhealthy shame.

Anticipatory shame When Liza (P02) who participated in my two-year study remarked after her miscarriage that “I don’t feel as adequate as before” and “I feel fearful of what others may think of me after the loss”, she was anxious of what others would think or say about her for failing to carry the baby to full term while other women had succeeded. Social exclusion theory argues that based on evolutionary grounds, one of the reasons groups exclude or reject others is due to the perceived incompetence, uselessness or unattractiveness of the individual (Baumeister & Tice, 1990). Therefore, Liza could be fearful of the social exclusion or reduction in her status or social rank as the result of her “failure”. This perception then precipitates within her what is called anticipatory shame (Anderson, 2018; Nicols, 1991; Rebellion, Piquero, & Tibbetts, 2010; Wurmser, 1981). Anticipatory shame is often described as a discretion that is experienced as an anxiety about being disgraced to motivate people to conform to social norms and

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expectations. In other words, such shame is felt “before the fact” and it functions as a prosocial emotion to help us conform to social norms and inhibits behaviour that risks public shame and humiliation, thus safeguarding the boundaries of the self (de Hooge, Breugelmans, & Zeelenberg, 2008; Pines, 1995). Anticipatory shame actually contributes to a harmonious social life for humans. Indeed, both Kaufman (1995) and Keltner, Young, and Buswell (1997) argued that shame is evoked when a person’s secured social bond is threatened or disrupted. This explains why another participant, Amy (P01), avoided talking about her miscarriage when her patient asked her why she was absent from her clinic for some time. She must have felt an unpleasant sense of anticipatory shame and thus became too anxious to want to talk about her loss. As observed, anticipatory shame will generate within the person some form of shame anxiety to prompt that person to avoid exposure to shame. Shame anxiety as a secondary emotion is often accompanied by some other emotions. The type of accompanying emotions depends on the context of the situation, and in the English language, we have different words to describe those aggregated feelings of anticipatory shame. For example, in the area of protecting our physiological privacy, anticipatory shame can be experienced as modesty to hold back someone from exposing his nakedness (Schneider, 1977). Concerning our sexuality, anticipatory shame can be experienced as shyness and coyness to restrict sex to intimate relationships in private (Nicols, 1991). Concerning the psychological aspects of privacy in safeguarding between a person’s self-as-known-by-oneself and self-as-known-by-other, anticipatory shame can be experienced as a sense of discretion over one’s appropriate self-disclosure (Tedeschi, 1986). Thus, underlying all these modes of potential humiliation is the shame anxiety brought about by anticipatory shame as a component of healthy shame to guide our social behaviour.

Vicarious shame Another participant by the name of Jo (P07) made the following remarks during one of the interviews: My mother is also taking it badly. Already, she is taking Xanax for her depression. She was expecting a grandchild this year. She knew she is a girl and she’s not particular for a son. My mother said she had a dream of the baby asking why I abandoned her. It was a big let-down for her. Maybe it is disgrace manifesting as disappointment. She feels shameful, thinking why other families can have the blessings of children of the next generation but not ours? Jo’s mother was in fact vicariously feeling the shame of her daughter’s perinatal loss as her own shame. It is a form of public shame where one feels shame over the shame of another. In a wider sense, a member of the public can feel the shame over the shameful or shameless acts of a person or group of persons. This is what is termed as vicarious shame (Welten, Zeelenberg, & Breugelmans, 2012). Such a

Healthy shame 57 term is similar to what Li, Wang, and Fischer (2004) called reactions to shame, other-focus in the Eastern perspective of shame. Indeed, shame functions in most cultures as a social control mechanism to varying degrees. According to Fung and Chen (2001), the controls may be more extensive and elaborate in collectivistic cultures. In Chinese culture, for example, shame is commonly used as a prominent technique of social control (Fung, 1999). Hence, shame to the Chinese is not a mere human emotion but also a virtue to be pursued (Hwang, 1987; Schoenhals, 1993). However, such controls are effective only when the people have a strong sense of vicarious shame in that they must feel such shame and proactively sanction anything that is deemed by society as shameful or shameless. In this respect, vicarious shame is often experienced as a healthy fear of social stigma or public disgrace. To reiterate what is mentioned in Chapter 7, social stigma is based on an act of categorization where a person is identified as a member of a social group that is regarded negatively. On the other hand, public disgrace is the result of a person’s own actions that violate social norms and triggers the social sanction of shaming. The social process of bringing public disgrace is humiliation by others. Hence, public disgrace is closely related to the loss of dignity and honour for the targeted persons. These are the basic psychological dynamics that enable vicarious shame to serve its role in social control.

Clinical implications At the present time, most of the popular psychological techniques for addressing shame do not make a clear distinction between healthy and unhealthy shame in their interventions. However, in trying to help people suffering from issues of shame through our interventions, we must be careful that in doing so, we do not stifle their sensitivity to experience healthy shame. This is possible only if therapists fully understand and appreciate the fact that anticipatory and vicarious shame are healthy components of shame to keep us more human by signalling the relational boundaries of ourselves and others. The currently popular approaches to address shame include psychoeducation group work (PGW) and cognitive-behavioural therapy (CBT). PGW is best illustrated by Brene Brown’s 12-session Connections Curriculum (Brown, 2009; Brown, Hernandez, & Villarreal, 2014), which advocates four common characteristics, namely, (a) understanding shame and recognizing triggers, (b) practicing critical awareness, (c) reaching out and sharing the story and (d) “speaking” shame. CBT techniques to address shame include exercises for building selfacceptance so that there is a sense of mastery over thoughts and feelings rather than being controlled by them. For example, Sanderson (2015) believes that in CBT, “the most powerful antidote to shame is empathy and compassion, both for self and others” (p. 229). To cultivate empathy and compassion, she has exercises for clients to “see things from others’ perspectives without judgement, and recognize and communicate our understanding of emotions to others as well as to ourselves” (p. 237).

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When people have problems with their shame because it is so unbearable for them and they undergo PGW or CBT, there are two issues involved. First, if the problems involve certain situations which make them feel so shameful that they want to seek relief through psychological intervention, but the cause is due to their low threshold for tolerating healthy shame and not due to their unhealthy shame, then we can end up only help them in coping with their shameful situations and in the process, stifling their healthy shame or making them more shameless. Second, if their shame problems involve the overuse of certain defence mechanisms to protect them from the pain of unhealthy shame and those mechanisms have since become maladaptive and affecting what is considered as normal behaviour, then PGW or CBT may not be effective in helping them fully. This is because both of these approaches only help the person to cope with shame at the conscious level, and as we will see in greater detail in the next chapter, unhealthy shame arises from the unconscious level within the person. In other words, cognitive insights and management techniques will not be sufficient to address what is from the unconscious level (Alexander & French, 1946).

Bibliography Alexander, F., & French, T. M. (1946). Psychoanalytic therapy: Principles and application. New York, NY: Ronald Press. Anderson, J. M. (2018). The dynamics of shame in the Eden narrative. Sydney, Australia: Australian Catholic University. Baumeister, R. F., & Tice, D. M. (1990). Anxiety and social exclusion. Journal of Social and Clinical Psychology, 9(2), 165–195. Brown, B. (2009). Connections: A 12-session psychoeducational shame resilience curriculum (2nd ed.). Minneapolis, MN: Hazelden. Brown, B., Hernandez, V. R., & Villarreal, Y. (2014). Connections: A 12-session psychoeducational shame resilience curriculum. In R. L. Dearing & J. P. Tangney (Eds.), Shame in the therapy hour (pp. 355–371). Washington, DC: American Psychological Association. Dearing, R. L., & Tangney, J. P. (2014). Introduction: Putting shame in context. In R. L. Dearing & J. P. Tangney (Eds.), Shame in the therapy hour (pp. 3–19). Washington, DC: American Psychological Association. Fung, H. (1999). Becoming a moral child: The socialization of shame among young Chinese children. Ethos, 27, 180–209. Fung, H., & Chen, E. C.-H. (2001). Across time and beyond skin: Self and transgression in the everyday socialization of shame among Taiwanese preschool children. Social Development, 10, 420–437. Hwang, K. K. (1987). Face and favour: The Chinese power game. American Journal of Sociology, 92, 944–974. Kaufman, G. (1995). Shame: The power of caring. Boston, Mess: Schenkman. Keltner, D., Young, R. C., & Buswell, B. N. (1997). Appeasement in human emotion, social practice and personality. Aggressive Behaviour, 23, 362–369. Li, J., Wang, L., & Fischer, K. W. (2004). The organization of Chinese shame concepts. Cognition and Emotion, 18(6), 767–797.

Healthy shame 59 Nicols, M. (1991). No place to hide: Facing shame so we can find self-respect. New York, NY: Simon & Schuster. Pines, M. (1995). The universality of shame: A psychoanalytic approach. British Journal of Psychotherapy, 11(3), 346–357. Rebellion, C. J., Piquero, N. L., & Tibbetts, S. G. (2010). Anticipated shaming and criminal offending. Journal of Criminal Justice, 38(5), 988–997. Sanderson, C. (2015). Counselling skills for working with shame. London, England: Jessica Kingsley Publishers. Schneider, C. D. (1977). Shame, exposure, and privacy. Boston, MA: Beacon. Schoenhals, M. (1993). The paradox of power in a People’s Republic of China middle school. Armonk, NY: Sharpe. Tedeschi, J. (1986). Private and public experiences of the self. In Roy F. Baumeister (Ed.), Public self and private self (pp. 1–20). New York, NY: Springer-Verlag. Welten, S. C. M., Zeelenberg, M., & Breugelmans, S. M. (2012). Vicarious shame. Cognition and Emotion, 26(5), 836–846. doi:10.1080/02699931.2011.625400. Wurmser, L. (1981). The mask of shame. Baltimore, MD: Johns Hopkins University Press. de Hooge, I. E., Breugelmans, S. M., & Zeelenberg, M. (2008). Not so ugly after all: When shame acts a commitment device. Journal of Personality and Social Psychology, 95(4), 934.

10 Unhealthy shame

We have seen that healthy shame exists as a natural emotion in every person. Shame is only classified as unhealthy when it is experienced in a disproportionately greater intensity or frequency than the level of that person’s first response to a similar shameful situation. Unhealthy shame has two basic components: acute and internalized.

Acute shame The quantitative section of Chapter 6 established that there are high bivariate correlations between the number of past shame incidents, the significance of their impact and the intensity of present shame, suggesting that any significant shame incidents in the past, especially those during childhood and involving trauma or relentless repetitions, can often predispose a person to be more sensitive to shame and at a higher intensity than normally experienced by other people. This seemed to be so with Jo (P07) as she narrated the following account: Lately, something happened that triggered my feelings of rejection and shame. I am not my normal self but extra sensitive to both feelings. The first incident was that we had a field trip outstation and there was a debriefing after that. The leader did not call me to share during the debriefing after everyone else had their turn. I felt so rejected. This brought me flashbacks to the time when I was very young and I discovered that my parents had a discussion with my sibling without including me. I remembered how rejected and shameful I felt then. During the return journey, there was also a remark jokingly said by one of the team members that they will have to stop again for me to pee. I immediately recalled the many occasions how my siblings ridiculed me for having to pee very often and this remark made me both hurtful and shameful. Then the team passed by a waterfall and they wanted to turn in and spend a little time there. I was not keen. One of the passengers in the car mentioned that if I am not keen to join them, then I can take a Grab taxi home. It was a casual remark but I took offence at that, equating it with the many occasions when my sibling rejected and shamed me in my childhood days. In all these cases, I just remained silent and emotionally withdrew myself from them.

Unhealthy shame 61 What Jo experienced in these incidents was undoubtedly a series of painful emotional sense of acute shame (Anderson, 2018). When past shaming experiences, particularly involving those in early childhood, remained unresolved, they get deeply etched in the person’s shame memories. Further external shameful incidents, including those which are only mildly shaming, can trigger off the unresolved shame of the old experiences and set off a disproportionate intensity of shame in that person beyond the normal and healthy level to what is termed as acute shame which is maladaptive and unhealthy. Acute shame is often painful enough to make the person want to hide and disappear. It directs the focus of the person inwards with negative self-evaluation, frequently conjuring up negative self-criticism and self-rejection. At the same time, acute shame can render the person to be externally hyper-vigilant towards any perceived negative evaluations by others (Matos & Pinto-Goavera, 2010). A person experiencing acute shame can even end up paralyzed in how to respond appropriately or become inarticulate, leading to difficulty in communication (Lynd, 1958). We saw some facets of this in the aforementioned narrative account of Jo.

Internalized shame When intense or acute shame is first experienced following an external shaming situation, and that shame remains unresolved, the emotion remains inside of us. Similar shaming incidents will add to the internal collages of shame, magnifying its effect to an extent a further trigger will be so unbearable that the individual will unconsciously suppress it from surfacing. This results in the internalization of shame which is accumulated and stored in our shame memory in the realm of the unconscious. When shame is internalized, it no longer needs to be activated by what is external but it can be triggered internally and the person will feel shameful for being ashamed of himself. Internalized shame is thus the most toxic component of shame. Kaufman (1996) further elaborates on the internalization of shame as follows: These scenes become directly imprinted with shame when the expression of any affect, drive or interpersonal need is followed by shaming. Sufficient and necessary repetitions of the particular affect-shame, drive-shame, or interpersonal need-shame sequences create the internalized shame linkage or bind. When the expression of any affect, drive or need becomes associated with shame, then later experiences of these affects, drives, or needs spontaneously activate shame by triggering the entire scene. Shame need no longer be directly activated. (p. 84) According to writers such as Kaufman (1996), Miller (1985), Nichols (1991), and Pinto-Gouveia and Matos (2011), a key task of socio-emotional development is identity formation. Healthy identity formation is essential for effective social functioning. A healthy identity has a clearly defined and realistic self-concept, high

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self-worth and a positive self-esteem that is characterized by a sense of adequacy which says, “I am okay, lovable and acceptable”. It is this sense of identity that the internalization of shame lurks to corrode. This is because with the repeated experiences of acute shame taking place without any reparatory experiences to affirm one’s identity and social standing, the resulting internalization of shame will serve to modify the person’s identity to be shame-bound with an abiding sense of not being good enough, unlovable, fundamentally flawed, unworthy or unacceptable (Nichols, 1992). Indeed, Tangney (1990) states that internalized shame is evidenced by shame-proneness, a low self-esteem or a shame-bound identity. We note that Jo’s ISS shame score taken during the quantitative survey was 54. The ISS scale of 50 to 59 represents frequent experience of shame and ≥60 as high shame, with 96 as the maximum score. Her score was indicative of acute shame. In narrating her three painful emotional incidents, she also said, “I am having less confidence on myself now. In fact, I feel less spiritual after the loss. I am inadequate, like I am in another place. I sense much shame and I am not myself”. In emphasizing her sense of much shame and inadequacy, she is saying that her identity has been adversely affected by her perinatal loss, and reading this together with her ISS score, she was thus showing traits of internalized shame.

Clinical implications To avoid experiencing the intense pain of unhealthy shame, the individual will usually adopt certain defence mechanisms as a psychological shield. For every person, the early child-caregiver experiences along with the child’s inherited dimensions of temperament shape his or her personality and the regular but often unconscious use of certain defence mechanisms. Recent discoveries in the field of neuroscience tell us that 85% of a child’s brain has been developed by the time he or she reaches the age of five. Such development in the brain includes the vision, motor and emotional faculties, social attachment and language/math skills. So, by five years old, all of us have our preferred defence mechanisms that have become integral to our own coping styles. However, the overuse of certain defence mechanisms can make them dysfunctional or symptomatic as they affect what is considered as normal behaviour and are thus maladaptive. Helping the person cope and manage his maladaptive psychological symptoms at the level of his defence mechanisms will not eliminate the unhealthy shame as it arises from the unconscious level of our memories. Hence, Kaufman (1996) advocates psychodynamic intervention for addressing unhealthy shame. To him, this is an evolving integration of four central process dimensions. First, the therapeutic process must actively restore the interpersonal bridge by creating a reciprocal therapeutic relationship. Second, by adopting a developmental focus, internalized shame is reversed to its interpersonal origins or governing scenes. To accomplish this, shame must be made fully conscious, along with its current sources and originating scenes. Third, by focusing on making conscious and then reshaping how the self actually functions as a self in the present, there will be regrowth of identity and healing of shame. Clients must create with the help of

Unhealthy shame 63 the therapist new self-affirming dialogues to replace the old ones. For example, a self-blame script can be substituted with giving oneself the human right to make mistakes. A comparison-making script can be replaced with an active respect for self. Fourth, interpersonal relations must be changed to directly foster equal power in current relationships, especially in the family of origin. For instance, by learning how to make their own stand with parents and other people, adults are enabled to let go of their past and live life in the present. Some of these application aspects of this intervention are adapted in Part 2 of this book.

Bibliography Anderson, J. M. (2018). The dynamics of shame in the Eden narrative. Sydney: Australian Catholic University. Bradshaw, J. (2011). Healing the shame that binds you. Deerfield Beach, FL: Health Communications Inc. Kaufman, G. (1996). The psychology of shame: Theory and treatment of shame-based syndromes (2nd ed.). New York, NY: Springer. Lynd, H. M. (1958). On shame and the search for identity. New York, NY: Harcourt Brace. Matos, M., & Pinto-Goavera, J. (2010). Shame as a traumatic memory. Clinical Psychology and Psychotherapy, 17( 4), 299–312. Miller, S. (1985). The shame experience. Hillsdale, NY: The Analytic Press. Nichols, M. (1992). No place to hide: Facing shame so we can find self-respect. New York, NY: Simon & Schuster. Pinto-Gouveia, J., & Matos, M. (2011). Can shame memories become a key to identity? The centrality of shame memories predicts psychopathology. Applied Cognitive Psychology, 25, 281–290. Tangney, J. P. (1990). Assessing individual difference in proneness to shame and guilt: Development of the self-conscious affect and attribution inventory. Journal of Personality and Social Psychology, 59(1), 102–111.

11 Continuum of shame

The labelling of the different basic components of shame is an arbitrary char­ acterization according to their intensity along the continuum of shame. In particular, anticipatory and vicarious shame are classified as acute shame when it is experienced repeatedly and to a greater degree, thereby making that person feel worse than before. Hence, such intensities can be psychometrically calibrated from an extreme state of zero shame we term as shamelessness to a theoretical maximum score of 100 to represent an extreme state we term as shamefulness.

Prevalence of shamefulness Zuk-Nae Lee (1999) performed a study on the sense of shame in the Korean culture. According to him, the traditional Korean culture is based on Taoism which highly esteems the face-saving preservation of honour in the family, but under Western influence, the modern Korean culture has now come to focus on personal competence, mostly for the acquisition of material wealth. As a result, the crucial factor generating a sense of shame has shifted from failure of selfrealization in the Taoist culture and injury of the family in face-saving culture, to personal incompetence. For Malaysians who are equally impacted by the influ­ ences of the West, this is obviously true of Anne (first presented in Chapter 1). Her perceived personal incompetence and shaming by her Chinese school teachers had indeed led to her subsequent withdrawal and depression. However, rather than advocating a replacement of values, it would be more accurate to say that in modern Eastern culture influenced by the West, there are now more grounds that serve as causal factors to generate the sense of shame in addition to self-realization and injury in the face-saving preservation of honour in the family. This is evidenced by the high prevalence of shamefulness following the perinatal losses of Malaysian women in my two-year study which showed that some of them still feel very shameful for bringing shame to themselves and the family name in not fulfilling her expected role and duty to bear children. Indeed, it is noted that five of the participants’ internalized shame scale (ISS) scores (11.9%) are in the category of frequent experience of shame from 52 to 59 while another five participants (11.9%) are in the category of high shame from 61 to 89. In this respect, the ISS Interpretation Guidelines (Cook, 1994) state as follows:

Continuum of shame 65 It appears clearly from data with many clinical groups that a score of 50 or higher on the ISS is indicative of painful, possibly problematic levels of internalized shame. Score at or above this level may, therefore, be accompanied by defensive patterns that might be dysfunctional or symptomatic. Scores above 60 or higher may be considered very high or extreme and are more likely to be associated with more severe symptoms such as depression and/or anxiety. (p. 12) This indicated that a significant portion (total of 23.8%) of Malaysian women of Chinese background were having major problems with acute and internalized shame following their perinatal losses. Chapter 2 discussed on the hiddenness and social nature of shame and in view that the questions of the ISS assessment are not phrased at the interpersonal level to more effectively draw out the shame from its hiddenness, the prevalence of shamefulness arising from unhealthy shame can be even higher.

Prevalence of shamelessness Repeated disowning and disavowal of internalized shame over time can lead to an extreme condition of shamelessness. At the time of writing, there is very little psychological literature on shamelessness. Notwithstanding, there is an article in Psychology Today written by Leon Seltzer (2019) that describes shamelessness as an adaptation to escape from underlying feelings of shame. To him, shameless­ ness is a cover-up for deeper feelings of shame that the individual is either too scared or too defended to confront. In the shameless person’s effort to overcome feelings of shame, that person will subdue any sense of responsibility on his or her behaviour. There are also limited Eastern literature on shamelessness, but the teachings of Confucius have something to say about it. In particular, Li, Wang, and Fischer (2004) pointed out that “In Chinese culture, if a person is perceived as having no sense of shame, that person may be thought of as beyond moral reach, and therefore is even feared by the devil” (p. 769). What is of great concern is that the quantitative surveys of my two-year study showed that the ISS scores of 14 participants (33.3%) are below 20. This sha­ melessness is of higher prevalence than shamefulness. The ISS Interpretation Guidelines state that “scores below 20 may indicate an avoidance for severe in­ ternalized shame” (p. 12). At the lowest end of the shame continuum, there is even one participant (D40) whose score is zero while another participant (D41) has a score of only 2. In particular, the responses of these two participants were checked carefully for random and inconsistent responding. Firstly, it is noted that all the responses of these two participants were not marked on a single point (like all 0’s) or selected in some patterned fashion (like 0, 1, 2, 3 and repeated), hence ruling out random responding. Secondly, there is consistency in the responses to the 24 shame items in comparison with the six self-esteem items which are negatively correlated, and thus ruling out incon­ sistent responding. Indeed, the reliability analysis of the ISS questionnaire used in this survey demonstrated a very strong internal consistency for shame in the current sample (α = 0.97) and a fairly strong internal consistency for self-esteem

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in the current sample (α = 0.83). In any case, ISS scores like zero or 2 would tantamount to extreme cases of shamelessness.

Continuum of shame Now that we have established the two extreme poles of the shame continuum, let us work on an appropriate model to depict shame in its entirety. As an example of how shame is commonly portrayed in Western psychological literature, we note that the psychometric scale of the ISS (Figure 11.1) focuses more on the harmful and pathological aspects of shame.

Low

Shame

Frequent Experience Of Shame

High Shame

Avoidance 0

Internalized Shame 20

Figure 11.1

50

60

96

The ISS Psychometric Scale on Shame.

When we embrace a fuller understanding of shame with both its healthy and unhealthy adaptations, a more balanced and comprehensive continuum of shame that spans from extreme shamefulness to extreme shamelessness will look like what as shown in Figure 11.2. Unhealthy Shame

0 Shamelessness

Figure 11.2

Healthy Shame

33

Unhealthy Shame

66

100 Shamefulness

Normal Shame

A Proposed Comprehensive Continuum of Shame.

By putting in the different basic components of shame in the healthy and unhealthy zones where they operate, we can further depict the inner dynamics at work throughout the continuum of shame, as shown in Figure 11.3. Disavowed shame

Anticipatory shame

Acute shame

Disown

Interact

Intensify

Internalized shame

Vicarious shame

Internalized shame

Unhealthy 0 Shamelessness

Figure 11.3

Healthy 33

Unhealthy 66

Normal Shame

A Proposed Dynamic Continuum of Shame.

100 Shamefulness

Continuum of shame 67 Under normal shame, anticipatory shame interacts with vicarious shame to evoke healthy shame which is adaptive and beneficial to both the individual and society. Shame becomes unhealthy when our internalized shame memories in the unconscious intensify the shame either from an external source or inner perception to make it acute, often resulting in shamefulness. The opposite band of unhealthy shame involves the disowning of internalized shame that is constantly intensifying the acute shame which even the habitual use of defence mechanisms is unable to shield, thus producing disavowed shame that leads to shamelessness. The dis­ tinctions become much clearer when we compare between Figures 11.1 and 11.3. When we depict the continuum of shame as in Figure 11.3, we can have a wider and deeper understanding of shame.

Incorporating the setting The Proposed Dynamic Continuum of Shame can be further expanded to in­ corporate the setting in which shame operates. Whereas Figure 11.3 only shows the intrapersonal dynamics of shame, the expanded diagram will show the chain of interpersonal factors at work: Since we are not alone but relate to one another, social constructionism episte­ mology posits that knowledge and realities are constructed through discourse and conversation (Gergen, 2009). In other words, meaning and experience are socially produced and reproduced, rather than being just inherent within the individuals (Burr, 1995). Using Figure 11.4, the manner in which shame is subjectively experienced by the individual is also influenced by the global trends and cultural mindsets of his environment at a particular time. These macro factors undergird

Global trends and Cultural Mindsets towards Shame Societal and Situational Perceptions and Expectations towards the Issue at Hand Verbal and Non-verbal Behaviours and Words of Significant Others Interpersonal Level

Social (In)validation: Stigma

Intrapersonal Level

Predisposition to Shame: Disgrace

Disavowed shame

Anticipatory shame

Acute shame

Disown

Interact

Intensify

Internalized shame

Vicarious shame

Internalized shame

Unhealthy 0 Shamelessness

Figure 11.4

Healthy 33

Unhealthy 66

Normal Shame

100 Shamefulness

A Proposed Dynamic Continuum of Shame with Setting.

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Understanding shame

the societal and situational perceptions and expectations towards the issue which has the potential to threaten the individual with shame. Then such perceptions and expectations are expressed particularly through the verbal and non-verbal beha­ viours and words of other people. As we have seen in Chapter 7, due to the stigma on a certain issue not sanctioned by a particular society, even though no in­ validation words are specifically expressed, an uncomfortable gaze, silence or avoidance is enough to trigger a disgrace in the shame-prone person. Hopefully, future studies and psychometric assessments that have such a wider coverage on the continuum of shame incorporating both the intrapersonal and interpersonal dynamics at work will help us better address our psychological interventions for shame in individuals as well as confronting the problems of shamefulness and shamelessness in society as a whole.

Bibliography Burr, V. (1995). An introduction to social constructionism. London, England: Routledge. Cook, D. R. (1994). Internalized shame scale: Professional manual. Menomonie, WI: Channel Press. Gergen, K. J. (2009). Relational being, beyond self and community. New York, NY: Oxford University Press. Lee, Z.-N. (1999). Korean culture and sense of shame. Transcultural Psychiatry. Advance online publication. doi:10.1177/136346159903600202. Li, J., Wang, L., & Fischer, K. W. (2004). The organization of Chinese shame concepts. Cognition and Emotion, 18(6), 767–797. Seltzer, L. (2019). Shameful or shameless – If you had to, which would you choose. Retrieved from https://www.psychologytoday.com/us/blog/evolution-the-self/ 200911/shameful-or-shameless-if-you-had-which-would-you-choose.

Part II

Addressing shame

12 Getting to the roots

After practising professional counselling and psychotherapy for many years, I am more convinced than ever before that many of our psychological problems are rooted in our unhealthy past shame memories. People may come to see a counsellor or psychotherapist because of their depression, compulsive behaviours, abusive violence, gambling addiction or a host of other mental problems, without a clue that shame may be the source of most of these manifestations. Unless we resolve the underlying shame which causes them, we may be just treating the surface symptoms. Let me elaborate on this point by using a case of clinical depression.

The typical approach to treat depression Depression is often called the “common cold” of mental illness. At any one time, one out of ten persons suffers from major depression and almost one out of five persons has suffered from this disorder during his or her lifetime (Kessler et al., 1994). The common approach to treat depression is a combination of self-help, medication and talk therapy. Self-help: Depression can make even the simplest tasks of daily living very tough, but there are some self-help measures that one can take to feel better. The counsellor or psychotherapist will often educate the client on these measures or the client can also source them from the Internet. They include: a b c d e f g h i

Exercise daily to maintain good health; Make some adjustments to reduce stress at work and at home; Practise relaxation techniques such as deep breathing and meditation; Organize and plan your daily routines so that you can manage them better and look forward to each day; Eat healthily and do not overeat; Maintain a regular sleep routine to get enough sleep and do not sleep too much; Curtail alcohol and substance abuse; Seek help from family members, friends and support groups; Take personal responsibility for your recovery.

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Medication: A wide range of antidepressants is used to treat the symptoms of depression. The modern generation of antidepressants is called selective serotonin reuptake inhibitors (SSRI) which help to increase the level of the “good mood” chemical in the brain called serotonin. Examples of SSRI include fluoxetine (Prozac), paroxetine (Seroxat) and citalopram (Cipramil). Newer antidepressants include serotonin-noradrenaline reuptake inhibitors (SNRI) which change the levels of both serotonin and noradrenaline in the brain. Examples of SNRI include venlafaxine (Efexor) and duloxetine (Cymbalta). As different individuals respond differently to the drugs, it is a matter of trial and error which one works best for the person. Although SSRI has fewer side effects than the earlier antidepressants, some people still experience nausea, headaches, mouth dryness and erectile dysfunction while SNRI can cause high blood pressure. Antidepressants are not addictive but when one abruptly stops taking them, withdrawal symptoms are common. When treatment by drugs does not work well, electromagnetic brain stimulation is sometimes adopted to pass an electric current to certain parts of the brain to alleviate the symptoms of depression. The techniques include transcranial direct current stimulation (tDCS), repetitive transcranial magnetic stimulation (rTMS) and electroconvulsive therapy (ECT). The more invasive ECT serves to trigger a seizure and it is used especially when the depression is very severe or life-threatening. Talk therapy: There are various psychological approaches used to treat depression but among the talk therapies, there is consistent evidence to show that cognitive therapy is more effective than the other techniques. In particular, a metaanalysis of 28 studies has indicated that there is a greater degree of change when cognitive therapy is used compared with the other treatments (Dobson, 1989). Notwithstanding, it is recommended that the therapist works with the client in combination with the self-help measures and medication, and only when good progress is evident that the client is advised to phase out the medication under the close supervision of his or her psychiatrist. In modern application, since thoughts and actions influence our feelings, talk therapies to address depression will usually include cognitive-behaviouralrelational dimensions. In particular, clients are taught on specific ways to change their thoughts and actions to improve their moods which are monitored by a selfassessed Daily Mood Scale (Beck & Steer, 1987). Thoughts are the ideas that we tell ourselves and so clients are helped to restructure their negative and destructive thoughts to positive and constructive ones. They are also taught to recognize the mistakes of faulty thoughts and talk back to those thoughts that depress their moods. Actions are monitored in terms of their daily activities and social interactions. For depressed people, the less daily activities that they do, the more depressed they feel. Hence, they are taught to increase those daily activities which make them feel better, firstly by rating and identifying what are the activities they enjoy doing, and secondly, by setting the short-term and long-term goals to be involved in those activities. With regard to social interactions, it is noted that

Getting to the roots

73

people are more depressed when they have less contact with others as social support is essential to see us through hard times. Depressed clients are hence encouraged to go out to meet and interact with others by doing something that they really like in the company of other people, and at the same time, staying away from overly negative relationships.

Physiological and psychological causes It is clear that the typical approach to treat clinical depression focuses more on reducing the outward symptoms of depression by intentionally and aggressively changing the negative thoughts and actions. Indeed, the process involves a constant cognitive effort aimed at alleviating the mood of depressed persons based on the assumption that their thoughts and actions influence their moods. However, the reverse is equally true in that our emotions also influence our thoughts and actions. In fact, our thoughts, actions and feelings influence each other in circular and multi-dimensional ways. Indeed, depressed people often tell us that there are days when their moods are so low that they do not feel like doing anything related to changing their thoughts, daily activities or social interactions. So, the critical question we should be asking is why do certain people wake up in the morning feeling very low in their moods? It is obvious that if they are not disturbed by their low moods, then they do not have a problem with depression in the first place. The medical profession emphasizes that this is because there is an imbalance in certain chemicals in our brain and as we have seen in the preceding section, there are medications to correct such deficiencies. However, the medications at best will only alleviate the depressed moods but they do not cure our bodies from producing those moods because when the person stops taking the antidepressants, the depressed moods will often come back. Thus, we need to understand that depression is a mental illness that has both physiological and psychological roots. These roots are often referred to as nature and nurture, operating either singly or in combination. Physiologically, depression can run in the family, passed down the generations through the genes which make the individual more susceptible to depression when experiencing stress or trauma. However, as explained in Chapter 4, the intense stress or trauma experienced through the nurture of the child from day one right through to the later years of adulthood can also cause the same chemical imbalance in ordinary persons with no family record of depression. As medication can only treat the physiological deficiencies and alleviate the symptoms, the patient will continue to suffer from depression because the psychological roots are not addressed. Thus, taking cognitive efforts to restructure our thoughts and actions to influence our feelings or taking medications to alleviate the depressed moods only serve to manage the symptoms but does not eliminate the negative emotions from coming out from within the person. Hence, to treat depression effectively at its roots, we need to address the psychological problems which cause the negative emotions that in turn generate the symptoms.

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Addressing shame

Why we develop the symptoms? When a person experienced intense or repeated shame either during childhood or later in life, the shame that remained unresolved will begin to accumulate, become more acute and then get internalized to adversely affect even one’s core identity. To avoid experiencing the pain of such unhealthy shame, the individual will usually adopt certain defence mechanisms as a psychological shield to block the unpleasant feelings. However, the overuse of these defence mechanisms can make them dysfunctional or symptomatic. According to Nathanson (1993), one typical defence strategy adopted to escape from the pain of internalized shame is withdrawal. Withdrawal means hiding or running away from any potentially shameful incidents so that the internalized shame lying suppressed in the unconscious shame memories have no chance to get triggered off to further shame the individual. Hence, we see in Chapter 1 that Anne, who was constantly shamed by her school teachers for not completing her homework, tried hard to avoid anything potentially shameful by shying away from any real or perceived harming stimulus to the extent of not asking her professors or course mates any questions even on what she did not understand in her university studies for fear of ridicule. Unfortunately, Anne came to a breaking point in her final year when she could not catch up with her studies and her mind went totally blank. Besides the intense sadness and the diminished ability to think or concentrate, she also experienced insomnia, fatigue, psychomotor retardation and feelings of worthlessness, present beyond a two-week period, most of the day and nearly every day. (These are the five or more of the nine symptoms listed by the Diagnostic and Statistical Manual, now in its fifth edition called DSM-5, to qualify as a major depressive disorder.) Besides her sadness, she was also anxious over the prospect of letting her father down and feeling ashamed with her old school classmates when they learned about her “failure”. According to Nathanson (1993), sadness and anxiety are the two affects typical of many types of depression. Indeed, Anne spiralled deeper and deeper into clinical depression and was unable to continue with her course. She was referred to me by her father after she had gone through one year of conventional treatment for depression and taking the antidepressant medications while in the United States. In this respect, a study by Gilbert (2000) has shown that shame, social anxiety and depression are highly related. In another study, Andrews (1995) concluded that childhood and adult abuse were both independently related to chronic or recurrent depression. Not only Anne suffered the shameful abuses of her teachers while at school, she was also excessively pressured by her father to perform well in her studies. In fact, it was her father’s idea that she pursued a university course in science. He is an avid admirer of the late astrophysicist Stephen Hawking but more importantly, he wanted her to prove to her school teachers and classmates that she is smarter than them. Feeling inferior from being looked down by the people in school and despite being shy and withdrawn, she agreed to her father’s wishes and pushed herself beyond her limits into clinical depression.

Getting to the roots

75

In Chapter 2, it was pointed out that shame arises when one perceives he is falling short of his own expectations on himself or what others expect of him. What the person aspires to become is called the ideal self and what the person perceives of himself in reality is called the actual self. Anne’s ideal self is someone who can prove to her school teachers and classmates that she is smarter than them as well as someone who can live up to her father’s expectations of her. These aspirations were rigid and demanding on her. When she could not keep up with her course work, it became obvious to her that there was a widening gap between her ideal self and her actual self with regard to her academic aspirations, resulting in more shame, more withdrawal and a spiral into depression.

What can we conclude from here? From the above illustration, we can summaries as follows: a

b

c

d

Most of our mental health problems have physiological and psychological roots. Hence, even as modern medication can correct the physiological deficiencies, we also need to rectify the psychological causes. Further, many of the cognitive techniques we currently adopt in counselling to address the psychological issues only help us to control or manage their symptoms without eliminating the roots that cause the symptoms in the first place. As such, although we may be able to feel better and function as normal more often, we are not healed of the psychological illness and continue to be dependent on the drugs and our constant efforts to subdue the symptoms. The symptoms develop because certain defence mechanisms are habitually and unconsciously overused until they became maladaptive or dysfunctional, thus affecting behaviour that is considered by society as abnormal. These defence mechanisms are initially adopted as a psychological shield to protect the person from the unpleasant feelings of unresolved shame accumulated and internalized in the unconscious realm of the self in the form of unhealthy shame memories. Since the unhealthy shame memories reside in the unconscious, cognitive techniques that operate at the level of awareness will not be effective to restructure the shame issues. So, the natural tendency is for the individual who is weary of his cognitive efforts to resort back to the same defence mechanisms in the threat of shame, whether real or perceived. This results from his constant battle to fight against the use of the defence mechanisms to prevent the symptoms from surfacing, and when that fails, there is added shame against shame. Therefore, the intrapersonal dynamics of shame means that many of the contemporary techniques adopted to address shame, whether in one-to-one therapy or in psychoeducational shame resilience group sessions, will not effectively resolve the psychological root causes of shame because they are cognitive in nature while the unhealthy shame memories reside in the unconscious. In fact, neuroscience researchers believe that the unconscious

76

e

Addressing shame constitutes as much as 95% of our memories (Allen, Wilkins, Gazzaley, & Morsella, 2013; Morsella, Godwin, Jantz, Krieger, & Gazzaley, 2016). It is also possible that cognitive techniques can end up starving off or subduing our sense of healthy shame which is essentially a natural emotion inherent in all of us to keep us more human through signalling our relational boundaries. As we have seen in Chapter 11, the consequence of shamelessness is harmful and blatant public misbehaviours that will cause major social problems in society. In addition, clients having problems with shame will usually come to see a counsellor or therapist complaining of some mental health symptoms but not because of the shame since there is shame of the shame. Therefore, the more complete approach to address shame is first to attend to the symptoms by the conventional ways to manage or cope with them, then connect the symptoms to the defence mechanisms which cause the symptoms, and finally resolve through the unconscious the internalized shame memories so that those defence mechanisms are no longer required.

Bibliography Allen, A. K., Wilkins, K., Gazzaley, A., & Morsella, E. (2013). Conscious thoughts from reflex-like processes: A new experimental paradigm for consciousness research. Consciousness and Cognition, 22, 1318–1331. Andrews, B. (1995). Bodily shame as a mediator between abusive experiences and depression. Journal of Abnormal Psychology, 104(2), 277–285. doi: https://doi. org/10.1037/0021-843X.104.2.277. Beck, A. T., & Steer, R. A. (1987). Manual for the Beck depression inventory. San Antonio, TX: The Psychological Corporation. Dobson, K. S. (1989). A meta-analysis of the efficacy of cognitive therapy for depression. Journal of Consulting and Clinical Psychology, 57(3), 414–419. Gilbert, P. (2000). The relationship of shame, social anxiety and depression: The role of the evaluation of social rank. Clinical Psychology and Psychotherapy, 7, 174–189. Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Hughes, M., Eshleman, S., . . . Kendler, K. S. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the US: Results from the National Comorbidity Survey. Archives of General Psychiatry, 51, 8–19. Morsella, E., Godwin, C. A., Jantz, T. K., Krieger, S., & Gazzaley, A. C. (2016). Homing in on consciousness in the nerves system: An action-based synthesis. Behavioural and Brain Sciences, 39, e168. doi:10.1017/SO140525X15000643. Nathanson, D. L. (1993). About emotion. Psychiatric Annals, 23(10), 543–555.

13 Connecting the symptoms to shame

As healthy shame is a natural emotion that serves human beings a vital function to regulate our social boundaries, therapists attending to shame-related clients must be careful not to give them the impression that all uncomfortable experiences of shame ought to be quenched. We want to leave healthy shame and the everyday experience of its fleeting presence intact so that it can continue to nudge us when we transgress our social boundaries. Hence, our present focus is on attending only to acute and internalized shame as these are the unhealthy shame components and we do this by first being aware of the type of symptoms which are set off by them through the unconscious use of defence mechanisms initially adopted to shield the individual from the pain of such shame.

Initial awareness of the link When a client presents himself or herself as having certain psychological issues in the form of abnormal behaviour, the therapist’s first response should be focused on symptomatic intervention to relieve the suffering. As we have seen in the preceding chapter, the most common symptomatic intervention for symptoms of depression consists of self-help measures and cognitive-behavioural therapy, often combined with medication prescribed by a psychiatrist. For obsessivecompulsive disorder, we can adopt exposure and response prevention techniques. For domestic aggression and physical violence at home, we can apply couple therapy techniques such as reframing, reappraisal and empathy-based collaborative alliances as well as anger management strategies. For gambling addiction, we can try cognitive restructuring and financial/time management training as well as the imaginal desensitization techniques. Indeed, there are many different intervention techniques claimed by their founders and advocates as most effective for various types of psychological problems. As we carry out these symptomatic interventions, the therapist needs to be aware at the back of his or her mind that certain symptoms are likely to be linked to unresolved shame memories as its root cause. It is mentioned earlier that there is vast empirical evidence linking shame to many psychological problems (Harder & Lewis, 1987; Tangney, Wagner, & Gramzow, 1992). Indeed, Dearing and Tangney (2014) reiterate that “empirical findings confirm the long-standing

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Addressing shame

Table 13.1 Symptoms and What Ultimately Caused Them Psychological symptoms/presenting issues Withdrawal symptoms: Hiding; running away; shyness; silence; evasiveness; loneliness; superficiality; emotionally unavailable; stuttering; anxiety; posttraumatic stress disorder; hyper shame vigilant; highly sensitive to rejection; isolation; low selfesteem; depression; agoraphobia; sexual abstinence; impotence or frigidity Attack-self symptoms: Shyness; false modesty; self-deprecating humour; self-effacement; selfneglect; self-humiliation; deference; subservience; self-injury; selfsabotage; self-debasement; obsessivecompulsive disorder; masochism; bulimia; anorexia; refusing medication; self-mortification; suicidal ideation Attack-other symptoms: Ridicule; humiliation; bully; put-down; teasing; insults; anger; rage; banter; sarcasm; hostility; intimidation; aggression; physical violence; murder; abusive relationships; domestic and sexual abuse; exploitation or violence; vandalism; antisocial behaviours; rape; sexuallymotivated murder Avoidance symptoms: Arrogance; self-deception; narcissism; grandiosity; alcohol, sex, drugs, exercise or food addiction; insatiable wealth accumulation and consumer spending; exhibitionism; competitive comparisons; religious mysticism; thrill-seeking or risk-taking behaviours; perfectionism; pathological lying; inner emptiness

Purpose of the defence strategy By becoming virtually invisible, silent, secretive or isolated to be away from the scrutiny and judgment of others physically and psychologically so that one cannot be shamed at all.

By engaging in the intentional derogation of the self and being differential, complaint or submissive to others in order to gain approval, avoid the fear of abandonment or deaden the inadequate self to annihilate the shame within.

By projecting one’s shame onto others and shaming them through becoming aggressive to overpower them or elicit superiority so as to escape one’s own shame.

By seeking to distract or redirect one’s focus through activities, enhanced body image, possessions, or competency to cover up the defective self in an effort to disown or disavow the unbearable feelings of shame.

clinical literature indicating that frequent experiences of shame contribute to individual vulnerability to psychological distress” (p. 6). Table 13.1 presents a wide range of the symptoms generated by the four different defence strategies as described by Nathanson (1993) to be commonly adopted to shield against shame.

Connecting the symptoms to shame 79 Note that the symptoms that we want to go right to their roots are those which are considered as dysfunctional or maladaptive as compared with what society accepts as normal behaviour. As the intensity of shame exists in a continuum, only the dysfunctional or maladaptive symptoms are indicative of being originated from acute or internalized shame. Many of the mild and fleeting forms of the same symptoms are in fact considered by society as normal, healthy and not pathological. If required, these can be dealt with through the normal counselling techniques at the level of awareness without proceeding further into addressing the unconscious shame memories. For example, a modest display of shyness in the presence of strangers will obviously not be considered as abnormal behaviour that merits any psychological treatment. In certain Eastern cultures, this is even the type of good behaviour expected of young girls. Shyness is a withdrawal symptom to protect against shame only when it becomes a constant barrier to daily interpersonal interaction such that it adversely affects one’s quality of relationships with others. Even so, a good portion of clients can be effectively taught to manage or cope with his or her shyness using cognitive counselling techniques. However, when the shyness is indeed a habitual unconscious strategy to stay away from the scrutiny and judgment of others physically and psychologically so that one cannot be shamed at all, then that shyness needs to be addressed at its roots through shame memory reframing as laid out in the following chapters. This is the case for Anne where the intensity of her shyness is causing her to be dysfunctional. In addition, we cannot presume across the board that shame is the only root cause of each of the dysfunctional or maladaptive symptoms as there may be other causes such as stress, chemical imbalances and personality disorders. For example, a person who is seen as a frequent risk-taker need not be displaying an avoidance symptom to protect against shame because he has a borderline personality since young and he does not know his boundaries with regard to his behaviours. Likewise, depression may be linked to other factors, apart from shame, and requiring differing treatments. In this respect, Morrison (2014) stated that the “relationship between shame and depression is clinically important in that treatment implications and emphases differ considerably from those depression that reflect loss and/or internally directed aggression and guilt” (p. 30). Neither can we say that resolving a certain past shame memory will eliminate the presenting symptoms once and for all since there may be a host of other issues still stored in the shame memories and not addressed yet. In any case, before we can start to address the shame memories in the unconscious realm of the client, the therapist has to help the person gain the insight regarding the link between the presenting symptoms and the shame within so that he or she will believe and participate fully in the therapeutic process.

Surfacing the shame Shame is inherently hidden both from the self and from others, and the client will be fearful of exposing the shame from its hiddenness and experience its

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unpleasantness. Surfacing shame from its hiddenness is thus an essential part of the therapy process. In other words, the client must first be made to be more aware of how they react in the face of shame. Since uncovering shame will intensify the experience of shame, the process must be managed carefully so as not to cause any collapse of the good rapport built up between the therapist and the client. Such collapse can result in the premature termination of the counselling relationship commonly referred to as a therapeutic rapture. For instance, when the therapist senses that there is a cover-up for shame like a certain evasiveness, humour or politeness to rescue oneself from going further in the dialogue, then one must gently explore with the client the reason for the need to adopt such a face-saving strategy. This must be done in an atmosphere of openness, empathy and trust. Most importantly, the therapist must not be judgmental against the client at all times. In other words, shame has to be unmasked very gradually in order to maintain the empathic connection. When surfacing the shame, its unpleasantness can often become intolerable to the client. To enable the client to better tolerate the pain of shame when it is generated, Kaufman (1996) advocates a technique he terms as refocusing attention. As the attention of the person is turned inwards when shame is generated, refocusing attention involves a conscious act of the will to refocus one’s attention away from the self by becoming immersed in some external sensory experience. I adopt a similar technique called grounding which is often used in combination with deep breathing and relaxation for clients experiencing a panic attack. For sensory refocusing, clients are asked to name five things they see around them and five sounds that they can hear at that moment. Such grounding will re-orientate their focus from the spiral of the affect of shame back to the reality of the present moment, thus lessening its impact. Again, this is only a cognitive effort and it does not resolve the underlying shame at the level of the unconscious.

Making the connection Next, the link has to be established between the presenting symptoms, the defence strategy at work and the underlying shame. The following verbatim with Anne illustrates how the connection is eventually made with her. This took place at the fifth session after working with her on the symptomatic intervention for her depression over the last four sessions. Therapist: You said that for some time before you broke down, you were feeling very sad and anxious. Why do you think you were feeling very sad? Anne: I was very sad because I could not understand a lot of what was taught in the lectures. Therapist: Is that why you also became very anxious? Anne: Yes, if I am not able to catch up, I am going to fail in my exams. If I fail in my exams, what will my former classmates think of me?

Connecting the symptoms to shame 81

Therapist: Anne:

Therapist: Anne: Therapist:

Anne: Therapist: Anne: Therapist: Anne: Therapist:

Anne: Therapist: Anne:

Therapist: Anne: Therapist: Anne: Therapist:

Anne: Therapist:

Anne: Therapist:

Besides, I will be letting my father down for sending me to study in the States. And so, as you got very sad and anxious, what else happened to you? Increasingly, I was unable to concentrate, cannot sleep, and always very tired. Then I had bouts of panic attack and during one of the lectures, I just blacked out. That’s when you went to see a psychiatrist and he diagnosed you as having depression? Yes, that’s right. Now, let me backtrack a little. Please help me to understand that when you were not able to follow fully what was taught, did you not read up or do some research on what you did not know? I tried but many of the concepts were just too complicated for me to understand. In fact, for the later lectures, I was totally lost! Did you ask your course mates to help you? I don’t mix around with them. I usually kept to myself. Did you ask your lecturers to explain to you what you did not understand? No point asking. I’ll still not understand. I sense there is a little evasiveness in your reply. Can I explore with you if there are other reasons why you did not want to ask your lecturers for help? They will ridicule me and say I am stupid. Why do you say that? Because they are all the same. When I was young, there was once when I asked the teacher in my school on something, she scolded me in front of the whole class that I did not pay attention when she was teaching and called me an idiot. I was so embarrassed. Did this kind of situation happen often? Many times. I was ridiculed many times for all sorts of reasons, so much so that I was scared to ask my teachers on anything. Is that why you did not want to ask your professors for help? (head lowered, eyes looking down) Yes, I think so. I noticed that when you said “yes”, your head was lowered and your eyes were looking down. What does that mean to you or what are feeling inside of you? I am feeling shameful, like all the ridicule and humiliation just happened yesterday. They feel like yesterday because as we talk about why you shy away from asking your professors to help you, that triggers off the past shame memories of the shaming you suffered back in school. Please explain to me why I am so shy to ask my professors? Whether it is your shyness, or your initial evasiveness when we talked about that, or the isolation from your course mates, they are all part of a defence mechanism we call withdrawal. You have adopted such a

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defence strategy to avoid any risk of further shaming so that your past shame memories will not get triggered off. But the usage of withdrawal as a defence mechanism has been so habitual that it becomes part of you and unconsciously, you just withdraw from people and feel shy to approach anyone for fear of being shamed. Anne: So, is there any help for me? Therapist: There is help for you but first I must explain to you what shameinformed therapy will involve if we are to proceed with this in the subsequent sessions.

Bibliography Dearing, R. L., & Tangney, J. P. (2014). Introduction: Putting shame in context. In R. L. Dearing & J. P. Tangney (Eds.), Shame in the therapy hour (pp. 3–19). Washington, DC: American Psychological Association. Harder, D. W., & Lewis, S. J. (1987). The assessment of shame and guilt. In J. N. Butcher & C. D. Spielberger (Eds.), Advances in personality assessment (Vol. 6, pp. 89–114). Hillsdale, NJ: Erlbaum. Kaufman, G. (1996). The psychology of shame: Theory and treatment of shame-based syndromes (2nd ed.). New York, NY: Springer. Morrison, A. P. (2014). The psychodynamics of shame. In R. L. Dearing & J. P. Tangney (Eds.), Shame in the therapy hour (pp. 23–43). Washington, DC: American Psychological Association. Nathanson, D. L. (1993). About emotion. Psychiatric Annals, 23(10), 543–555. Sanderson, C. (2015). Counselling skills for working with shame. London, England: Jessica Kingsley Publishers. Tangney, J. P., Wagner, P. E., & Gramzow, R. (1992). Proneness to shame, proneness to guilt, and psychotherapy. Journal of Abnormal Psychology, 101, 469–478. doi:10.1037/0021-843X.101.3.469.

14 Preparing for shame-informed psychotherapy

As we have learned from the preceding chapters, the dysfunctional or maladaptive symptoms are generated by the unconscious use of the defence mechanisms to shield against the past memories of unhealthy shame. Therefore, these past shame memories have to be resolved so that there is no more necessity to use those defence mechanisms. Furthermore, as these memories reside in the unconscious, cognitive efforts at the level of conscious awareness will not be effective and therapy must target at bringing about changes in the unconscious.

Can past shame memories be changed? Neuroscience tells us that memories are formed by the reactivation of a specific group of nerve cells called neurons through the persistent changes in the strength of connections between them. These connections are called synapses and the persistent change in the strength of the connections is termed as synaptic plasticity. Synapses are made stronger or weaker depending on how often they have been activated in the past. A memory is stronger when the connections are active but when these connections are seldom used, the memory gets weaker and may eventually disappear. It was said that neurons that fire together wire together. As an analogy, strong memories are likened to busy highways whereas weak memories are like scarcely-trodden pathways that will soon be overgrown with vegetation and disappear over time. Thus, synaptic plasticity means that through changing the strength of existing synapses, new memories can be added and old ones can be removed. In this regard, past shame experiences, especially the traumatic and/or repeated ones, will make a person more vigilant towards threats of shame, and when further shame cannot be avoided, as in the case where a certain defence mechanism is not protective enough, the past toxic shame memories will get triggered. What are triggered are usually those similar to the shame circumstances but depending on the intensity of the triggers, even those memories that are distantly related to the situation can be set off. Thus, for a shame-bound person, the toxic shame memories become very strong because they are frequently activated. Therefore, in order to address unhealthy shame, the critical issue is how to get rid of those past toxic shame memories. The answer lies in the creation of healthy memories reframed out of those same past shame events so that there are

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alternative routes for the synapses to travel on when shame is triggered. When there are alternative routes, the old toxic shame memories will get less activated, become weaker and eventually disappear. So, change is possible but it is not often a type of immediate transformation as it involves a process of unconscious memory switches. The good news is that we can create the healthy alternative routes that are associated with specific toxic shame memories without reliving those events in real life. We used to believe that it is only our external or reality experiences that create the memories inside of us. Actually, reality is about how we perceive what we experience through our senses. Now, neuroscience researchers have found that mental imagery can change our multisensory perceptions (Berger & Ehrsson, 2013). In other words, our imagination can create reality at the neuronal level. For example, most of us already know about the practice of athletes using mental imagery to help them in their performances by imagining a specific accomplishment before acting on it.

Process of reframing through imagery To heal shame through imagery, the process first involves getting into the unconscious memory of an acute shame incident as it was originally experienced and making it fully conscious. Getting into one such memory requires preparatory work by the client. The therapist will ask the person to spend some time during the course of the preceding week to reflect and recall as far back as possible some of the most shaming incidents of the past that she wants to resolve. Usually, this refers to the most disturbing incidents involving high intensities of shame. If these incidents remain completely obscure, then she may need to try to discover an entrance to those memories by observing some of the most common inner voices that frequently haunt her, telling her, for example, “you are always a failure”. It is this type of negative script that Anne linked herself to some of the acute shaming incidents she suffered under her school teachers. At the start of the imagery session, the therapist will tell the client to close her eyes, relax and imagine herself walking into her past memories. At some point, she will select to enter into the memory of an original acute shame incident that she wants to resolve. Tomkins (1979) first coined the words governing scene to refer to such an original memory. Next, the details and the affects that have been defended against by shame need to be recovered and consciously re-experienced. The client will be asked to talk about the surroundings, like noticing the arrangement of the furniture, the colour of the wall, even the smell of the air in the venue. Then she will be asked to relive the shame scene, sequence by sequence, by first describing who were there and what took place. In the process, she must try to re-experience, name and verbalize as far as possible the shame and all the other affects she experienced at the original scene. The reason why the governing scene must be relived completely is to fully release all the affects embedded in the memory. It is the affects that energizes the synapses that make them more active and releasing the affects will weaken that particular shame memory.

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As the client relives the original shame scene, as real now as it was happening then, the therapist will ask the client to imagine bringing into the scene someone who can rescue her from the shame. This someone is the person whom she looks up to and is perceived by her as having the stature to put right what is wrong. This person can be real or imagined, alive at that time or already dead. Thus, the rescuer can be the internalized “good” parent, aunt, or the therapist, a hero or leader whom she idolizes, or even God. Then the therapist will ask the client to imagine the rescuer saying what she needs to hear and doing what she wants to be done to vindicate her from her shame. Under the guidance of the therapist, the client must verbalize every word that is said, every action that is taken, and all the positive affects experienced by her during the vindication process. The purpose is to repair the shame of her original experience to create through imagery a favourable memory out of the same past shame scene as an alternative route for the synapses to travel. When this is done, the client is asked to imagine coming out of her memories, walk back to where she came from, and open her eyes. After a short rest, the therapist can ask the client for feedback and review the process with her.

Enhancing the outcome with experiencing The use of imagery to change memories is not new. It was Bronowski (1971) who first wrote on the concept and use of imagery while Tomkins (1979) further developed on it. Kaufman (1996) also elaborated on the use of imagery to reverse the development sequence of toxic shame memories and true to his psychodynamic tradition, the therapist becomes the internalized rescuer of his clients. In modern times, and particularly in the East where brief therapy is the norm, the therapeutic relationship may not have reached the stage where the client is ready to internalize the therapist as the trusted, good rescuer inside of her. It may also not be so real to the client for the therapist whom she knew only now to appear in the shame scene that took place years ago. Therefore, the rescuer in the reparative imagery adopted here can be anyone whom the client has confidence in. In this respect, shame memory reframing through imagery is a corrective emotional experience first defined by Alexander and French (1946) as re-exposing the patient, under more favourable circumstances, to emotional situations which he could not handle in the past. In other words, the patient, in order to be helped, must undergo a corrective emotional experience suitable to repair the traumatic influence of previous experiences. Knight (2005) argued that corrective emotional experience is a good reparative technique in psychotherapy. To be effective, therefore, shame memory reframing through imagery has to be experienced as real as possible to the client in that the original shame scene as well as the reparative scene which has to be vividly imagined as actually taking place inside the person. The “experiencing” is key for the technique to be effective. This refers not only to experiencing vividly the original and reparative scenes, but more importantly, it includes sensing the accompanying affects aroused by them. As stated above, sensing and verbalizing the embedded shame and other related

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affects that serves to energize the synapses will weaken the targeted toxic shame memories. At the same time, sensing and verbalising the intense positive feelings towards oneself as the client is vindicated by the internalized rescuer will effectively create strong reparative scenes as new memories to gradually replace the weakened governing scenes of the old shame memories. That is why the client must first be explained thoroughly the basis of the technique, believe in the process and willingly subject oneself to undertake the therapy.

Enhancing with symbolic acts In addition, as the shame lies embedded in the unconscious, symbolic acts can be very effective in making real the disowning of the shame accumulated through the original shaming incidents and repeated reactivations. Symbolic acts with their outward expressions when taken seriously can conjure up the emotions related to a vivid scene even though this takes place in our imaginations. For example, we often observe the powerful effect of symbolic acts as family members walk behind a hearse as symbolically sending off a loved one who has died and witness the overwhelming emotions of those moments. As explained in Chapter 4, generation shame is often passed down from shamebound parents or the client may have taken the responsibility of the shame from the shamer or abuser and this shame must be disowned by giving back to where it belongs. At the appropriate time during the reparative process, the therapist can lead the client to symbolically take the shame from her heart and dump it back to the original person. If such a person or persons cannot be identified, she can dump the shame into a box of shame. I often use the tissue box to conveniently represent the box of shame. Such a symbolic act of disowning the shame can serve to enhance the “experiencing” of the reparative process.

Bibliography Alexander, F., & French, T. M. (1946). Psychoanalytic therapy: Principles and application. New York, NY: Ronald Press. Berger, C. C., & Ehrsson, H. H. (2013). Mental imagery changes multisensory perception. Current Biology, 23, 1–6. Kaufman, G. (1996). The psychology of shame: Theory and treatment of shame-based syndromes (2nd ed.). New York, NY: Springer. Bronowski, J. (1971). The identity of man. Garden City, NY: Natural History Press. Knight, Z. G. (2005). The use of the ‘corrective emotional experience’ and the search for the bad object in psychotherapy. American Journal of Psychotherapy, 59(1), 30–41. Tomkins, S. S. (1979). Script theory: Differential magnification of affects. In H. E. Howe & R. A. Dienstbier (Eds.), Nebraska symposium on motivation (Vol. 26, pp. 201–236). Lincoln: University of Nebraska Press.

15 Application of shame memory reframing

Now that we understand more on shame memory reframing through imagery, this chapter will continue with the case of Anne to illustrate in detail how it is carried out. One week before the actual session, the therapist has already explained to the client how this technique fits in as a shame-informed therapy, why it works and what is involved. It is important that she believes in the technique and participates willingly and fully in the process. She has also been asked to reflect and recall on some past shame memories that have been traumatic or intense to her. The following verbatim is from Anne’s first session of shame memory reframing through imagery:

Verbatim of Anne’s case Therapist: Anne: Therapist: Anne: Therapist: Anne: Therapist: Anne: Therapist:

Anne: Therapist:

Anne:

Did you reflect on some of your past shame incidents? Yes, I went through that. Was it overwhelming for you? It’s unpleasant but manageable as a whole. I just reflect on them and try not to stay too long dwelling on any one incident. This is good. So, are you ready to have a go at the imagery exercise? Yes, I am ready. Before we start, is there anything you are uneasy about or anything you want to clarify? No, I’m fine. Now, close your eyes and relax your hands. Feel your legs and relax them. Now start to feel your chest and notice your own breathing within you. Breathe in to a slow count of three. Hold for three counts and breathe out to a count of three. How are you doing? I can sense my own breathing. Good. Now imagine you are reclining comfortably on a sofa by the seaside early in the morning. You hear the sound of the waves and feel the gentle breeze touching your face. You are now starting to feel very comfortable. Can you imagine the scene? Yes, I can sense the seaside before me.

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Therapist: Do you feel relax? Anne: Very relax now. Therapist: Now imagine that you are slowly looking to one side of you, and you see a door that opens the way to your past memories. Do you want to go into your past memories? Anne: Yes, I want to. Therapist: You can imagine yourself walking slowly to the door, then stretch out your hand to open the door and walk through it. Anne: (She lifts her right hand to open the door.) I am inside now. Therapist: Before you, you see a beautiful garden with a path leading from the door. On both sides of the path are signposts marking the memories of your past shame. Walk slowly along the path and select just one significant incident that you wish to re-experience. Anne: I have selected the incident. Therapist: Now enter into the memory of that incident. What do you see? Anne: I can see myself standing with my teacher in front of the class and all the students are staring at me. Therapist: What was your age then? Anne: I was about nine years old, like I was in Year 3 of primary school. Therapist: How’s the classroom like? Anne: It was in the morning. The classroom was very bright but the air was very still. Therapist: Why were you standing with the teacher? Anne: She wanted to punish me for not finishing my homework. She shouted loudly at me, “You stupid and useless girl! I will teach you a lesson that you will never forget”. Then she took the ruler and started hitting hard my palm for 29 times. Therapist: Why 29 times? Anne: I think it is for the 29 Chinese words that I did not finish writing. Therapist: How did you feel then? Anne: Physically, my palm turned very red and the pain was really sharp, eating into my flesh. I cried and cried. (Tears start to flow from her eyes and Anne is seen waving her right hand as though in pain.) It was so shameful being smacked over and over again in front of all my classmates. Even now, as I think back, I am feeling the shame and crying. (Wiping off the tears) Therapist: How are your classmates responding? Anne: I see many of them grinning their mouths in disgust as though they are saying, “Serve her right! Shame on her! She’s holding the class back”. Therapist: Ok, just stay there a little longer in that pain and shame. Note how hurting it had been for you. Anne: It’s very bad. Excruciating! Like my face got torn apart. (She squeezes her eyes tight.) Therapist: (Pause). Do you wish that there is someone who will speak up for you there and then, and rescue you from that pain and shame?

Application of shame memory reframing 89 Anne: Therapist: Anne: Therapist: Anne: Therapist: Anne: Therapist: Anne:

Therapist: Anne: Therapist: Anne:

Therapist:

Anne:

Therapist: Anne: Therapist:

Anne: Therapist:

Yes Who is this person? Auntie Mah Is she a real person? Is she still alive? She is a real person and she is still alive. Now, please imagine that she saw what happened and she just came into the class. I can see her now standing right now between me and the teacher. What did Auntie Mah do? She rebuked the teacher in a firm voice, “How can you call her stupid and useless? Do you know what harm you can do to this little girl? (Pause) Yesterday was the birthday of her grandmother and her father took her out to the grandma’s house until very late at night. You did not bother to ask why she had not completed her homework and you have been very harsh to her. Your continuous hitting of her palm in front of the entire class is outright abusive! You should be ashamed of yourself!” What happened next? The teacher just stood there dumb-founded and feeling guilty. She couldn’t say anything. How do you feel at this moment? I remembered I straightened up. (She in fact straighten up her sitting posture.) I feel I am vindicated. Yes, I did not finish my homework but it is not because I was lazy or disobeying the teacher. I was taken out of the house of my grandmother till late at night. I am not stupid or useless. I don’t deserve to be punished and shamed like that. I feel justified and I can lift my face up again. Now I want you to tell the teacher loudly that because she has shamelessly punished you in an abusive way in front of the class, the shame is on her and you can give your shame back to her. (With both hands, taking the shame from her heart and depositing it at her teacher) Teacher, I tell you that Auntie Mah has spoken out for me and you have unreasonably punished me in an abusive manner to shame me in front of the class. You should be ashamed of yourself! I take my shame out of me and give it back to you. You deserve the shame, not me! Good. How do you feel now? I feel good, like a heaviness has left me. Just stay with that good feeling for a few more minutes. (Pause) When you are ready, slowly walk back to the door where you came from. I am now back at the seaside where I started. Wonderful! Now you can come back to the room. Just open your eyes. (Therapist smiled as a welcome back gesture.) Do you think you have benefitted from what we did?

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Anne:

Definitely. I feel a weight has left me. I look forward to doing more to clear off the rest of my shame baggages.

Observing Anne’s physical actions such as lifting her hand to open the entrance door to her memories and waving her hand as though in pain as she was punished, her facial expressions such as tearing and squeezing her eyes tight as she verbalized her pain and shame, as well as straightening up when she felt vindicated, tells us that she is “experiencing” well and participating fully in the imagery process. Another indication of this was when Anne said as a feedback after the session that she could distinctively see the shame expressions on the faces of her classmates when they were still young and not what they look like now, thus showing that she is deeply into the governing scene of her unconscious shame memory. I did another three rounds of shame memory reframing through imagery on other shame governing scenes in the next three sessions and each time, Anne’s countenance became a little more and more cheerful. The best source of affirmation that the therapy has been effective and beneficial to the client is from the people closest to them. Immediately after the termination of Anne’s case at the end of her tenth session, Anne’s father gave me a text message to thank me profusely and said that he had seen a lot of improvement and optimism in her. He also informed me that she was talking with him about going back to the States to complete her studies.

Counteracting the inner vow After an intensely shameful experience, an individual will likely make an inner vow to avoid any further painful experience of the shame related to similar incidents in the future. An inner vow is a promise to oneself of what one will do or not do in order not to repeat what one has learned from a certain shameful experience. It can eventually form into an absolute guiding life principle to galvanize one’s choices and behaviours. An inner vow will define one’s priorities according to the negative aspirations or expectations that it holds. It is the underlying basis for certain unexplained external symptoms such as strong prejudices, irrational behaviours or disproportionate emotional reactions over any specific matter. Since an inner vow arises from the internalized shame memory, it can be counteracted and neutralized by the same work of shame memory reframing through imagery. During the exploratory discussion with the client over certain unexplained external symptoms, we can seek to establish their link with the inner vow and how is it worded. Then the therapist works out with the client on how the belief content of the inner vow can be modified to make it more forgiving and liveable. For example, Anne could have made an inner vow such as, “I will never allow myself to fail in anything that I do”. Such an inner vow would have driven her into perfectionism and any failure to meet the high expectations of herself would

Application of shame memory reframing 91 be extremely devastating to her. In therapy, Anne is led back to the governing scene and imagine herself telling the young student that she was then the exact words of her inner vow. Auntie Mah or someone she can look up to as her mentor is brought back into the picture, perhaps persuading her convincingly with the following wise words, “In life, we can only do our best as we are not in total control of the outcome of everything according to our expectations. Certain people may think negatively of us or even say unkind words to us. We can choose to accept whatever that will be helpful for us to improve our lives and reject whatever that we think is unjustified without being offended or shamed by them”. Then Anne is asked to verbalize the intentional replacement of her inner vow, for example by saying, “I now replace my inner vow of … with the guiding principle that …” The shame memory reframing session can be repeated from time to time to reinforce the replacement of the inner vow until the client is completely set free from the external symptoms.

Recovering disowned parts of the self Early relationship failures affect the child’s developmental phases of the self as well as the individual’s future behaviours. Traumatic experiences during childhood including incidents of intense or repeated shaming will impede intimate relationships and undermine one’s sense of security. The interpersonal origins of abuses, rejection, abandonment, humiliation and so on can be accessed through imagery to provide alternative reparative memories to the governing scenes to reown the disowned parts of the self. This re-owning can be accomplished through a technique which Kaufman (1996) calls reparenting imagery. Reparenting imagery uses the same process of shame memory reframing through imagery except that the client, now as an adult, is asked to enter into the governing scene and visualize meeting his own younger self often found in the form of a traumatized and humiliated little child tucked away inside of her. Upon connecting with this rejected “orphan” of her past, the client will now be the good parent-older sibling-rescuer, saying what the child needs to hear and doing what she wants to be done to right the wrongs, at the same time, feeling and verbalizing all the affects that come with the process. In this manner, the disowned parts of the rejected self can be slowly re-owned to form an integrated self with a reshaped identity. Reparenting imagery sessions can thus be carried out to supplement the effectiveness of shame-informed psychotherapy.

Bibliography Greenberg, L., & Iwakabe, S. (2014). Emotion-focused therapy and shame. In R. L. Dearing & J. P. Tangney (Eds.), Shame in the therapy hour (pp. 69–90). Washington, DC: American Psychological Association. Kaufman, G. (1996). The psychology of shame: Theory and treatment of shame-based syndromes (2nd ed.). New York, NY: Springer.

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Koerner, K., Tsai, M., & Simpson, E. (2014). Treating shame: A functional analytic approach. In R. L. Dearing & J. P. Tangney (Eds.), Shame in the therapy hour (pp. 91–113). Washington, DC: American Psychological Association. Morrison, A. P. (2014). The psychodynamics of shame. In R. L. Dearing & J. P. Tangney (Eds.), Shame in the therapy hour (pp. 23–43). Washington, DC: American Psychological Association.

16 Other antidotes to unhealthy shame

Having the right attitudes and perspectives in life also acts as antidotes that will make it more difficult for unhealthy shame to brew and boil over. Although this is not a substitute for the work of shame memory reframing, having the right attitudes and perspectives in life and knowing how to reinforce these values into our daily repertoire can serve as a supplementary measure against the negative effects of unhealthy shame. It is not a substitute because the process of applying the right attitudes and perspectives still involves the left brain cognition in our conscious awareness and not at the level of our unconscious.

Self-affirming scripts The quantitative findings of Chapter 6 highlighted the empirical evidence that there is a strong inverse bivariate correlation between shame and self-esteem. This relationship is indeed consistent with the findings of Yelsma, Brown, and Elison (2002). It means that by increasing our self-esteem, we can in some way also reduce our shame. Self-esteem has been stated earlier in the said chapter as a person’s sense of self-worth or how much we appreciate and like ourselves. When internalized shame corrodes the self-identity and produces low self-esteem within our core being, it churns out from within us self-dialogues that propagate negative expectations to propel us towards negative behaviour. Taking Anne as an example, her low self-esteem may suggest to her that she is stupid as a person and she will have a first negative script which says, “Because I am stupid, I will always make mistakes”. This inevitably becomes self-fulfilling and she finds herself often careless in her work. Soon, the self-blame script of her negative behaviour will snowball into a second negative script which is more self-condemning on her being like, “If I am stupid and careless, I will fail my exams, which means others will think that I am useless”. These deeper repercussions will further reinforce her negative self-concept and she will feel more dejected in her self-esteem. Thus, the continued corrosion of internalized shame on the self is repeated through its cycles. In this respect, it is most beneficial for shame-prone people with negative selfdialogues to take some time to monitor those inner voices, note and write down a list of their negative scripts. They must then proceed to create a corresponding new list of self-affirming scripts to commit to memory or serve as further

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reference when needed. It is ideal if the two lists are reviewed with the therapist to see if any revisions are necessary. Therefore, Anne’s first negative script can be rephrased as, “Everybody makes mistakes. Making mistakes is human and so I am not stupid”. Her second negative script can be restructured positively as, “My self-worth is who I am as a person, not what other people will think of me”. Thus, whether it is during her imagery sessions, or by her own self doing nothing, or engaging in real-life interactions with other people, she needs to consciously and actively monitor her inner voices, and when the situation warrants, immediately refocus back to her ready-made list of self-affirming scripts and replace those negative scripts with the positive ones.

Self-acceptance Anne’s self-affirming script that “My self-worth is who I am as a person, not what other people will think of me” is a statement of one’s attitudes and perspective in life that is loaded with positive meanings and values. Indeed, our self-worth should be anchored on the indisputable fact that everyone is a unique individual born with intrinsic worth, and solely based on this, each person deserves dignity and respect. In other words, we are who we uniquely are and our self-worth is not found in what we can do or cannot do. Performance is not part of the equation. Uniqueness means that one may be good in sports or in studies and the other person who only helps in keeping the house clean and tidy is just as useful and worthy. Uniqueness means that each person should accept his or her own differentness, whether good or bad in the sight of others, without judging oneself or feeling ashamed of our identity. At the end, self-acceptance is giving ourselves more leeway towards meeting the goals and aspirations of our ideal self and the process of easing the self-demands on our actual self should increase as we grow older. Our self-worth is also not dependent on what others have done to us as this is an imperfect world with injustices everywhere and anyone of us can be a victim of our circumstances. Injustices hit randomly and do not respect persons. But the fact is that the injustice of being neglected or sexually abused or intensely shamed does not change the self-worth of who we are as a birthright. Therefore, we need not bear the responsibility for the shame of the wrongdoer for the rest of our lives. We can choose to move on and grow in life based on the strength of our birthright and not get ourselves fixated on the baggage of our unfortunate experiences of the past. In addition, our self-worth cannot be made dependent on the opinions of other people because their opinions will change from one moment to the next and we are not in control of how they think. However, we are in control of how we see ourselves and no one can take that away from us. Therefore, we must learn to cultivate and maintain the self-acceptance of who we are as a birthright, including embracing our flaws and imperfections. We ought to be realistic by not trying to be what we are not although we should not give up in our lifelong quest

Other antidotes to unhealthy shame 95 to improve ourselves. As such, we cannot be just what others expect us to be, or even worse, end up feeling shameful for failing to meet up to their expectations. They may be our parents whom we want to obey or honour but at the end, we have to accept that we are different from others in terms of capabilities, talents and other natural emulations.

Judge not self Accepting our differentness includes letting go of any perfectionism over ourselves. Being so, we allow ourselves to make mistakes and not hide our vulnerabilities for fear of being judged by others. If we are not afraid of being negatively judged by others, then we will not be so easily shamed by them. After all, we are all humans and humans make mistakes as no one is perfect. The negative opinions of others over us can be taken as either beneficial feedback or unfair criticisms. If we consider them as beneficial feedback, then we ought to be thankful for them as they beneficially serve to correct or improve us. If we consider them as unfair criticisms, we can choose to discount or disregard them as we live in an imperfect world and people are likely to speak out of ignorance or solely for their self-interest. We need not safeguard our reputation since we already know our self-worth and has predetermined that what we are is not dependent on what others think of us. We have better things to do than to spend our whole life correcting the opinions of others about us. At the end, people will come to know and respect the truth about our right attitudes and perspectives in life. Therefore, we can be more empathetic and compassionate towards our own self without exerting excessive self-blame over our mistakes or imposing impossible expectations to compel us to excel. Replacing our self-judgment with self-compassion means to treat oneself the way we treat the other people whom we love and respect. This includes redefining any experience of shaming by laughing it off with a sense of humour and humility rather than taking it personally and judgmentally on our self and allowing the shame to cripple us. In other words, we must always be ready to forgive ourselves over our own mistakes or wrongdoings, because what’s important is not our faults but what we learn from them so as not to repeat the mistakes and be a better person.

Judge not others If we do not judge our own self harshly, likewise we ought to show others the love and respect that we accord to ourselves by not judging them harshly. The teaching of Confucius (Kong Zi, 551–479 BC) is that we are not to do unto others what we do not want them to do unto us. Putting it in reverse, Jesus Christ (3–33 AD) taught us that we are to do to others as you would have them do to you. Being so, we can reach out to connect with others with greater empathy and compassion. Obviously, this emphasis redirects us from focusing inwardly on our shame to an outward focus intended for the good of others.

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In many situations, withholding our judgment against others is not complete in itself if there is still a grudge held against others. We must also forgive them for their wrongdoings against us. We forgive because we live in an imperfect world and people do make mistakes and they deserve a chance to be able to change from their misdeeds. Most importantly, we forgive others so that we do not harbour unforgiveness within us to rob us of our inner peace and health. If we see shame as being evoked when a person’s secured social bond is threatened or disrupted (Kaufman, 1995; Keltner, Young, & Buswell, 1997), then forgiving others will maintain our secured social bond and disrupt the cycle of shame. So, learning to live and let live in such a manner by holding to these right attitudes and perspectives in life will mitigate our propensity to suffer the negative effects of unhealthy shame in us.

Bibliography Bradshaw, J. (2011). Healing the shame that binds you. Deerfield Beach, FL: Health Communications Inc. Kaufman, G. (1995). Shame: The power of caring. Boston, MA: Schenkman. Keltner, D., Young, R. C., & Buswell, B. N. (1997). Appeasement in human emotion, social practice and personality. Aggressive Behaviour, 23, 362–369. McKay, M., & Fanning, P. (2016). Self-esteem (4th ed.). Oakland, CA: New Harbinger Publications Inc. Sanderson, C. (2015). Counselling skills for working with shame. London, England: Jessica Kingsley Publishers. Yelsma, P., Brown, N. M., & Elison, J. (2002). Shame-focused coping styles and their associations with self-esteem. Psychological Reports, 90(3c), 1179–1189.

17 Therapist’s skills

Psychotherapy is both a science and an art. The science provides us with the techniques but the effectiveness of the approach is dependent on the quality of the therapeutic relationship and other common factors. Lambert (1992) concluded that techniques only account for 15% as a primary component of change. The relationship skills of the therapist account for the next 30%. Very importantly, the client must feel accepted, understood and safe. Next, the expectancy of the client to benefit from the therapy and get better covers another 15% while the remaining 40% has to do with the client and the extra therapeutic factors which have both internal and external features. The internal features refer to the client’s motivation, psychological attunement, emotional management and the like while the external features are the quality of his family, social, community and religious support. Since the relationship skills of the therapist is a major determining factor, this chapter examines several aspects of his skills in shame-informed counselling and psychotherapy.

Recognizing shame Shame is often staring right on to the face of the therapist without him recognizing the elephant in the room. One of the main reasons is that when a client comes to see the therapist, she will present her psychological problems but not link them to shame due to her own shame over anything that has to do with shame. The fact is that she is in fact already struggling with shame over the stigma of her mental unwellness and not being able to cope with it (Tangney & Dearing, 2014). This is particularly true of the face-saving Chinese people who see their inability to manage themselves well as personal failures (Chen, 2013; Dien, 1999). Further, Herman (2014) pointed out that due to the power imbalance between the client and the therapist and the perception that the client is expected to expose her intimate thoughts and feelings without reciprocity, the therapeutic relationship is also inherently shaming. Indeed, Dearing and Tangney (2014) emphasized that “clients who experienced unacknowledged shame in the context of therapy may feel misunderstood, resulting in an empathic failure on the part of the therapist” (p. 3). In that sense, every client should be treated as unique and with utmost care since a shame-bound

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person will often perceive her individuality and differences are either neglected or even specifically targeted for attack (Stadter, 2014). Therefore, it is imperative for the therapist to be thoroughly familiar with the two clinically useful indicators of shame described in Chapter 3 in order that he can accurately perceive and identify any shame that surfaces. When there are nonverbal physiological indicators such as facial signs, or a typical shame posture or awkwardness shows up, the therapist must highlight to the client at the optimal moment what he notices and gently explore her inner feelings and what those indicators meant to her. The same must be processed concerning the verbal psychological indicators such as any expressions of worthlessness, inadequacy or defectiveness. Since hidden shame is accessed through our awareness more readily when our attention is directed at the interpersonal level within a social context, whether real or imagined, one good question the therapist can ask the unadmitting client on noticing the shame indicators is, “Was there an incident in the past when you noticed the same signs showed up and if so, what emotions you felt within you at that time?” Often, if the discussion is conducted in a non-threatening manner, it will take the focus off the client from looking inwards to feel her shame, to attending to the narration of the incident in its interpersonal setting, and this will enable her to easily connect her non-verbal or verbal indicators of that situation to the current shame that is present in the counselling room.

Handling client’s resistance Similarly, and as explained in Chapter 13, some clients cover up their shame with evasiveness, humour or politeness to avoid surfacing it from its hiddenness. The therapist must then gently explore with the person the reason for the need to adopt such a face-saving strategy. At the onset of the therapy and at other strategic moments, it may be necessary to emphasize that everything that transpires in the sessions will remain strictly confidential within the four walls of the counselling room. Indeed, the therapist can help the client only to the extent she is willing to reveal the inner state of her being and the issues involved. So, I will often say to the client, “If you stay at the surface, I can only work with you to resolve the surface issues and this will be a waste of time for both of us. It is you that will determine how deep you want us to go”. Therapists will also inevitably face some clients who just talk continuously. In particular, if the client is talking on and on all over the place, the person may be trying hard either to avoid facing her shame or the incoherence may be due to some personality problems. In both cases, the therapist needs to be more directive and firm in repeating the question that he is asking to bring the presenting issue back into focus. On the other hand, some clients just maintain a deafening silence. The client’s silence can be a reaction of the threat to expose her shame. In such a situation, the therapist’s lack of an appropriate response or even silence will in fact intensify the shame for the client. Since the therapist’s task is to build up good rapport

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with the client so that the individual will feel accepted, understood and safe, I find that sharing one or two similar examples of previous cases of shame without stating the specifics will often put the person more at ease to open up. Needless to say, self-disclosures in normal counselling practice are done sparingly and at the appropriate moments for a specific purpose. In addition, client resistance occasionally shows up in the form of doubt over the genuineness and effectiveness in the use of imagery as a therapeutic approach. If this is the case, the therapist needs to revisit the preparation and psychoeducation stage as laid out in Chapters 13 and 14 to ensure that everything is explained clearly to the client at her level of understanding. In fact, it is easy to convince a client like Anne who has already taken one year of counselling elsewhere without much success to try something new. Again, sharing one or two previous cases on shame can instil the required confidence for the client to want to participate in the therapy process wholeheartedly. At the end, if the client is still hesitant to proceed, then it may be advisable to continue attending to the person with the cognitive and other appropriate treatments adopted since the beginning of the therapy. After one or two imagery sessions, when some improvement is likely to have been achieved and the client is feeling better, there may be some tendency to resist going further with the therapy to avoid experiencing more pain. I find it is best for the client to have at least three or four imagery sessions dealing with different governing scenes and when such resistance surfaces, I will switch the time to focus on psychoeducation such as revising, expanding and applying the list of new self-affirming scripts to replace the old ones, or discuss on the other antidotes to unhealthy shame as laid out in Chapter 16. When the client is more at ease, then only I will gently suggest that we should proceed with further imagery sessions to deepen the therapeutic work. If there is further resistance to continue, then stopping the therapy for the time being may be the next best alternative. As the option is open for the client to resume therapy at a later time, the person will not feel any loss of face when any inner conflicts resurface and help is again needed.

Some online therapy skills The Covid-19 pandemic of 2020 brought telehealth or online therapy sessions to the fore due to social distancing requirements and movement restrictions. The more frequent use of online therapy can in fact augur well for shame-informed psychotherapy although its effectiveness compared with face-to-face interventions has yet to be extensively studied and ascertained. This is because clients who harbour any stigma over seeking face-to-face mental health services can now do it from home without being seen by anyone in public. This is particularly the case for some Easterners who are overly conscious of maintaining their “face value” in the eyes of the community. In addition, online services offer more flexibility in fixing the schedules and hence provision can be made to accommodate even the busy working clients who can attend the sessions only after the office hours.

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All of a sudden, almost all counsellors and therapists who are used to providing their professional services on location are forced to learn to attend to their clients through video conferencing. Hence, this section will discuss some of the micro skills involved in running online therapy, especially where it pertains to shameinformed psychotherapy. At the onset, it is necessary to prepare the client as to what is the backup arrangement if Internet transmission is interrupted by electricity blackout or loss of signal. Further, since the therapy session can be recorded by the client without the therapist’s knowledge, it is best to seek the agreement of the client upfront not to do any recording for ethical or security concerns. Particularly with online therapy, clients will feel awkward during a session if there are moments of silence while facing the screen. It means that if the therapist is trying to do something with his laptop, he has to keep talking to the client by narrating what is going on at his end. So, it is good to engage the client with small talk at the beginning to help settle her down into the format. If the therapist still senses that there is further awkwardness, this has to be validated and discussed. In fact, it is always a good practice for the therapist to constantly clarify the meaning of the client’s expressions that carry any emotional overtones or the complete absence of them. In other words, instead of being able to note the client’s body language to supplement our visual processing in face-to-face sessions, the therapist will now have to learn to attune more on the auditory cues. Hence, it may be better to talk more slowly if we are not getting across clearly. It will also be helpful if the therapist uses more verbal tracking techniques such as reflection of content, clarification and summarization. At the same time, we need to constantly seek feedback more than we usually do in face-to-face interactions. This is particularly important when shame memory reframing is in progress. If this mode of therapy does not work well for certain clients, it may be necessary to revert back to the traditional location therapy when circumstances permit. We also need to be aware that for any online therapy, the attention span of the viewer is shorter than in location sessions. It is said that in the absence of active interactions from both parties, the viewer will likely get bored after 30 minutes and hence it will be difficult to stretch the duration of a session to beyond an hour. However, some shame memory reframing sessions may need as long as 90 minutes for them to be processed thoroughly and deeply. Again, it must be emphasized that if circumstances permit, the therapist may wish to arrange with the client for a limited number of location sessions just for this purpose.

Termination of therapy As a practitioner in the East where brief therapy is the norm, I usually commit my clients in advance to blocks of five weekly sessions. Before the fifth session, both parties will discuss if the client wants to proceed with the next block of five sessions. Hence, termination of therapy is never sudden as both parties will have some inkling if the next block of five sessions will continue or are no longer necessary. Even before the last session comes, the client will be prepared for the

Therapist’s skills 101 separation and encouraged to function more independently. In any case, clients will leave therapy on the understanding that they are welcomed to resume the sessions on an as-needed basis.

Bibliography Chen, W. (2013). Filial piety in confucian family values. Journal of Changchun Education Institute, 29(3), 69–70. Dearing, R. L., & Tangney, J. P. (2014). Introduction: Putting shame in context. In R. L. Dearing & J. P. Tangney (Eds.), Shame in the therapy hour (pp. 3–19). Washington, DC: American Psychological Association. Dien, D. S. (1999). Chinese authority-directed orientation and Japanese peer-group orientation: Questioning the notion of collectivism. Review of General Psychology, 3(4), 372–385. doi:10.1037/1089-2680.3.4.372. Herman, J. L. (2014). Posttraumatic stress disorder as a shame disorder. In R. L. Dearing & J. P. Tangney (Eds.), Shame in the therapy hour (pp. 261–275). Washington, DC: American Psychological Association. Lambert, M. J. (1992). Implications of outcome research for psychotherapy integration. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (pp. 94–129). New York: Basic Books. Stadter, M. (2014). The inner world of shaming and ashamed: An object relations perspective and therapeutic approach. In R. L. Dearing & J. P. Tangney (Eds.), Shame in the therapy hour (pp. 45–68). Washington, DC: American Psychological Association. Tangney, J. P., & Dearing, R. L. (2014). Working with shame in the therapy hour: Summary and integration. In R. L. Dearing & J. P. Tangney (Eds.), Shame in the therapy hour (pp. 375–404). Washington, DC: American Psychological Association.

18 Therapist’s shame

As shame can be contagious, the shame can easily spread from the client to the therapist (Herman, 2014; Morrison, 2014), since past shame is evoked not only with the client but also with the therapist, both consciously and unconsciously. This is particularly so if the therapist is himself shame-prone. In this case, the unresolved shame of the therapist can significantly influence the process and outcome of psychotherapy (Leith & Baumeister, 1998; Pope, Spiegel, & Greene, 2006). A brief description of three of the issues concerning the therapist’s shame is presented in this chapter.

Self-awareness Just as the therapist must learn to perceive and recognize the client’s indicators of shame, he must also monitor and accurately identify his own experience of shame during therapy as it can interfere with his objectivity in the process of his intervention. First, the therapist must be aware of his own unique physiological indicators of shame. For instance, I wrote in Chapter 5 that when I felt anxious over any threat of shame in my younger days, my index finger would start circling endlessly the shirt button next to my heart. Thankfully, I have not found myself doing this during the course of my professional practice. For other therapists, there may be physical signs such as the avoidance of eye contact, the lowering of the head, a rush of hot blushing to the face, or the slumping of the shoulders and overall posture. In addition, he may sense a certain uneasiness like embarrassment, awkwardness, frozenness, rapid hard rate or a need to withdraw. The therapist must then explore these indicators either inwardly by himself during the therapy or immediately after the session has ended. Such selfawareness will help the therapist to “compartmentalize” his shame from clouding his objective judgments and be fully present with his client. Alternatively, as Morrison (2014) has suggested, the therapist can “sometimes even by sharing (share) insights (with the client) about the therapist’s own shame” (p. 42). There are also the psychological indicators that the therapist must be aware of when they are evoked in the course of therapy. In particular, if a general sense of worthlessness, inferiority, inadequacy, defectiveness or emptiness emerges within the therapist as he empathizes with the shame of the client, this is clearly indicative

Therapist’s shame 103 that he is carrying his own unresolved shame into his professional work. Subsequently, the therapist can end-up unconsciously engaging in protective withdrawal, attack-self, attack-other and avoidance strategies (Nathanson, 1993) against the client. As noted before, attack-other strategies will quickly surface and be noted when contemptuous responses are directed at the client even at the beginning sessions. The other three strategies operate more subtly but their effect is to neutralize the impact of others and distort the quality of interpersonal interactions. Therefore, it is imperative for the therapist to be self-aware of his own experiences of shame, what are his typical defences against shame and how they manifest in his personal and professional relationships. Expressed as a general principle in psychological theory, the therapist must be aware of all the conscious and unconscious forces and patterns driving the client’s relationship with him (termed as transference) and he must be aware of all his feelings and modes of relating in response to the client (termed as countertransference) (Stadter, 2014).

Shaming and re-shaming Indeed, a cycle of shaming and re-shaming can be perpetuated in a therapeutic relationship when the early attachment experiences of the therapist were shaming and not addressed. This will leave him in a state of fear of intimacy with other people, particularly his clients. This shame-based fear of closeness will be reenacted by the therapist in adopting a detached professional stance during therapy or harping on intellectual theorizations of the presenting issues and resorting to prescriptive methodologies instead of genuinely attending relationally to the client’s needs (Sanderson, 2015). In turn, the client will perceive the therapist as uncaring, punitive and treating her as an object of shame. In such a situation, the client will likewise defend against the shame by withdrawal, attack-self, attack-other or avoidance. This may make the therapist feel misunderstood or unappreciated. If the therapist has problems in acknowledging or managing his own shame, he will personalize the reaction of the client as shaming him, eventually retaliating by anger, sarcasm, intellectualism or other means to shame the client and restore his superiority. Thus, the escalation of shaming and re-shaming will lead to an impasse and rapture of the therapeutic relationship. Therefore, the therapist needs to be watchful as to whose shame is being evoked at any specific stage of the therapy and how his shame can interact with the client’s shame to potentially escalate the cycle of shame. It is ideal that a therapist who intends to apply shame-informed counselling and psychotherapy first undergo personal therapy to have his own past shame experiences addressed so as to become more aware of his own shame when attending to his clients. One useful way to check if the therapy is tainted or not by the therapist’s own shame is to monitor whether the questions he put forward to the client are neutral or are they already loaded with certain value-judgments. Such regular monitoring will ensure that the therapist is hearing everything from the client’s perspective rather than trying to elicit what is corrupted by his own shame.

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Setting too high expectations There are other process dynamics which can elicit shame in the therapist. Amongst various authors, Morrison (2014) as well as Koerner, Tsai, and Simpson (2014) have also written on the sources of the therapist’s shame during therapy. According to them, the most common occurrence is identification with a client whose shame issues are similar to those of the therapist’s own unresolved shame. As mentioned earlier, this affects the therapist’s objectivity and full presence with the client. Another trigger point is taking too high personal responsibility for the success of the therapy. So, when the treatment outcome is less than desired, the therapist feels shameful over his performance. Such shame can even surface any time in the course of the intervention when the client is not showing much progress, implying that he is not competent or not helpful enough. In this regard, some young therapists often set for themselves high expectations that are just unrealistic to meet and needlessly end up feeling shameful over themselves. Sanderson (2015) has also touched on some of the almost unattainable expectations. One of them is setting rigid adherence to what is regarded by the therapist as a good ethical practice that stands in the way of maintaining a good therapeutic alliance with the client. Another danger is trying to be a perfect therapist by being legalistically 100% present with the client at all times during therapy or never getting distracted by the therapist’s own concerns. Yet another source of therapist’s shame can come from not liking certain clients when the therapist is expected to treat all clients equally. Awareness of such dynamics is healthy, signalling a need to talk over these issues with a colleague or supervisor so that the therapist can have an honest evaluation of himself to help him to be more authentic in his therapeutic relationship with his clients.

Bibliography Herman, J. L. (2014). Posttraumatic stress disorder as a shame disorder. In R. L. Dearing & J. P. Tangney (Eds.), Shame in the therapy hour (pp. 261–275). Washington, DC: American Psychological Association. Koerner, K., Tsai, M., & Simpson, E. (2014). Treating shame: A functional analytic approach. In R. L. Dearing & J. P. Tangney (Eds.), Shame in the therapy hour (pp. 91–113). Washington, DC: American Psychological Association. Ladany, N., Klinger, R., & Kulp, L. (2014). Therapist shame: Implications for therapy and supervision. In R. L. Dearing & J. P. Tangney (Eds.), Shame in the therapy hour (pp. 307–322). Washington, DC: American Psychological Association. Leith, K. P., & Baumeister, R. E. (1998). Empathy, shame, guilt and narratives of personal conflicts: Guilt-prone people are better at perspective taking. Journal of Personality and Social Psychology, 66, 1–37. Morrison, A. P. (2014). The psychodynamics of shame. In R. L. Dearing & J. P. Tangney (Eds.), Shame in the therapy hour (pp. 23–43). Washington, DC: American Psychological Association. Nathanson, D. L. (1993). About emotion. Psychiatric Annals, 23(10), 543–555.

Therapist’s shame 105 Pope, K. S., Spiegel, P. K., & Greene, B. (2006). What therapists don’t talk about and why: Understanding taboos that hurt us and our clients (2nd ed.). Washington, DC: American Psychological Association. Sanderson, C. (2015). Counselling skills for working with shame. London, England: Jessica Kingsley Publishers. Stadter, M. (2014). The inner world of shaming and ashamed: An object relations perspective and therapeutic approach. In R. L. Dearing & J. P. Tangney (Eds.), Shame in the therapy hour (pp. 45–68). Washington, DC: American Psychological Association.

19 Countering shamelessness

The rest of the world would say that China was able to keep 11 million people in Wuhan under total lockdown for two-and-a-half months in early 2020 following the Covid-19 outbreak because they have an authoritarian Government. In contrast, when Governments in the West imposed movement restrictions in their countries, there were sporadic disobediences, fierce arguments and violence against enforcement officers, even social unrest. It was also reported that more people in America were buying guns to protect themselves. But are there other factors beyond just the strong arm of the Chinese authorities that kept the millions of people in lockdown without any incidents of movement violations? It is noted that even under the same government, China had experienced isolated incidents of political protests in the past. Indeed, there is one underlying and obscure factor in China’s favour, and this is the important element of social cohesion arising from a strong sense of public shame amongst the people there.

Social cohesion vs social unrests Anticipatory and vicarious shame facilitate prosocial behaviour when people will strongly feel the shame for violating what is considered as the norm by society and actively sanction anything that is deemed by them as shameful or shameless. This is part of the Chinese culture passed down through the teachings of Confucius who considered shame vital for social cohesion. Therefore, the people of Wuhan were seen as more cohesive and united in fighting the coronavirus by putting community concerns above self-interests. Anticipatory and vicarious shame are the healthy components of shame. What is lacking in many parts of the world is a deficiency in acting on healthy shame as a natural emotion of humans, resulting in a rising state of shamelessness. For example, we can see shamelessness rampant in the political arena in many countries where politicians tell blatant lies without a single brink of the eye and bulldoze their personal agendas without the slightest regard to the hardships of the people they are elected to serve, or openly steal from public funds without any sense of shame. Likewise, during the time of movement restrictions at the height of the Covid-19 crisis when people were bored staying at home, we saw the increased circulation of pornographic materials and selfies shamelessly displaying the nakedness of one’s body.

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The indisputable point is that we are noticing more social unrests in the rest of the world than in China. Again, I wish to mention that this is not altogether attributed to an authoritarian Government but also to their strong sense of social cohesion which curtails shameless behaviour in public. As explained in Chapter 1, irresponsible behaviour in public is often the result of emotion dysregulation caused by an impairment of the higher order mental processing essential for considered, good and value-based decision-making when people are shameless. In fact, around the world but particularly in the West, the silent build-up of shamelessness may be unknowingly aided to some extent by the popularity of psychoeducation in shame resilience group therapies and working-against-shame personal therapies, many of which see shame as shame and do not make a clear distinction between healthy and unhealthy shame in their interventions. This clear distinction must be made not only in theory but more importantly in practice as the processes can end up stifling healthy shame while increasing shamelessness amongst the people. Indeed, we have seen in Chapter 11 that the data in my quantitative surveys had showed evidence of a high prevalence of shamelessness in our society.

Concern for rising shamelessness In addition, there are at least three broad trends that will further auger for the rise of shamelessness in the future with massive consequent sociological problems for society. First, people nowadays are a lot more mobile than previously. This means that if a person has done anything that is publicly shameful in the community where he lives and if he cannot face the shame, he can always move to another place where nobody knows him. As a result, people can afford to care less of their shamelessness. Secondly, due to technological advancement, a person can now have his own cyber community to which he feels a sense of belonging and purpose. This similarly frees him from having to face people in the community where he lives who will likely sanction him for any of his shameful or shameless public acts. So again, with this freedom, people will be more daring to behave more shamelessly. Thirdly, to many people, their job is their identity. Hence, losing their jobs and remaining jobless for a long time can be shameful, particularly for the men who are traditionally regarded as the breadwinners for their families. As a case in point, a June (2019) study entitled How Robots Change the World, What Automation Really Means for Jobs and Productivity from Oxford Economics projected that robots and automation will displace some 20 million manufacturing jobs by 2030. Obviously, the jobless situation is made much worse by the global Covid-19 pandemic of 2020. At the time of writing, recession is expected to hit the world economy. There is even talk of an impending depression far worse than the 1930s. To survive, the multitudes of jobless people will need to overcome their deep sense of shame by either addressing them in a psychologically healthy manner or they will end up suppressing and disavowing their shame and thus become more shameless. Financial hardship and shamefulness of the last Great Depression saw many suicides. Over the years, there has been a concurrent rise of

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Addressing shame

shamelessness. While financial hardship and shamefulness will also see many suicides in the coming depression, shamelessness will at the same time result in widespread public lawlessness.

Not socializing our children on shame As mentioned earlier, the consequence of shamelessness is irresponsible and harmful public misbehaviours that would cause major social problems in society. These misbehaviours are a source of what societies see as “untrustworthiness” in certain people. Although there are governments and local authorities in some countries experimenting on some kind of social credit system to reward good public behaviour and punish unbecoming behaviours that violate social and moral norms in society (Kobie, 2019; Kostka, 2018), these systems are at best external controls imposed on the people. External controls usually do not work very well in the same way that we can have laws and rules to prevent people from stealing and cheating, but they still steal and cheat anyway because they think they can get away with it without being caught. The interesting fact is that human beings have an inbuilt system for adhering to social and moral norms through healthy shame, but this natural system is underdeveloped and underutilized by society due to our Western preoccupation with the maladaptive form of unhealthy shame. As stated earlier, anticipatory shame functions as a prosocial emotion to help us conform to social norms and inhibit behaviour that risks public shame and humiliation, thus safeguarding the boundaries of the self. On the other hand, vicarious shame is shame over the shame of another, experienced and voiced over the public acts of others that are deemed shameful or shameless. Therefore, it makes sense for us to understand, cultivate and maintain the adaptive functioning of healthy shame within individuals for our long-term well-being and that of society. Since adults themselves do not understand the healthy and unhealthy dimensions of shame, many children grow up with either one of the two adverse shame conditions of shamefulness or shamelessness. On the one end, they are so abused in shame by their parents, teachers or other caregivers that they have a shame-bound identity held captive by acute and internalized shame. The other is that, since we are so predisposed to conceiving shame as being harmful or even pathological by Western psychological literature on shame (Creighton, 1990; Kaufman, 1996; Schneider, 1977), we end up having a strong aversion to shame, which includes not socializing our children in their shame. As a result, they grow up with an unsocialized sense of anticipatory and vicarious shame.

Application in society Many psychological theorists have posited that every emotion is subject to culturally patterned norms and assumptions and this requires a process of socialization (Kitayama & Markus, 1994; Lutz, 1988; Miller & Sperry, 1987; White, 1994). In the East, Miller, Fung, and Mintz (1996) have found that in Taiwanese families,

Countering shamelessness

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one of the shame socialization approaches involves the use of narratives as a didactic resource to enforce strict discipline. They do this with their children as early as two-and-a-half years old. Indeed, Fung (1999) sees the socialization of shame as the interactive and dynamic process by which a member inducts, structures and interprets the novice’s emotional experience in shame while the child accedes, resist or playfully transforms the messages and norms held out to him or her. The researcher studied nine middle-class Taipei families and made some observations which included the following: a b

c

d

Shame socialization is closely related to the notion of opportunity education by situating the lesson concretely in the child’s immediate learning experience. When the child transgressed in a wrongdoing, the caregiver is expected to bring the lesson to its fullest effect by shaming the child (e.g. bypassed when other children are given stickers or asked to face the wall). Shaming is not the ultimate goal but only a means to a goal. The purpose of shaming is to motivate children to take responsibility for their actions, know right from wrong and improve their behaviour. Shaming is hence accompanied by reasoning and a demand for confession. After the shaming, the caregiver must sympathetically reinterpret the transgression in the child’s perspective so that the child is protected from further shaming.

Likewise, Wilson (1981) in his studies in the Taiwanese primary schools discovered that the shaming with an element of ostracism or abandonment by the group was one dominant moral training technique to correct the child’s misdeed and emphasize the group’s disapproval. Needless to say that shame socialization must be an ongoing and dynamic process carried out in the context of a supportive and loving relationship involving the children’s active interpretation and construction of the ongoing semiotic activities. It is also important to ensure that shaming is not taken to the extreme as excessive and intense shaming under abusive and threatening conditions and without reframing actions can cause acute and internalized shame. In this respect, empathetic and a well-balanced form of shaming socialization ought to be part of the child-upbringing responsibilities of parents, teachers and other caregivers everywhere in the world. In addition, to cope with the rising trend of shamelessness, mental health services to help people address their acute and internalized shame experiences as well as their shame-bound identities must be readily available to those who need it. Thus, there is an urgent need for shame-informed counselling and psychotherapy services. In conclusion, the following long-term integrated approach to mitigate the foreseeable rise in shamefulness and shamelessness in society is recommended: a

The early socialization of shame for our children from a young age so that we have a “shame-socialized culture” (Schoenhals, 1993) with a good sense of healthy shame (anticipatory and vicarious);

110 b

c

Addressing shame Making easily accessible shame-informed mental health services for people who need help to cope with their unhealthy shame (acute and internalized) so that they can address their shamefulness and do not end up disavowing their shame to result in shamelessness; An ongoing mental health awareness campaign to psycho-educate people to know the full nature and implications of healthy and unhealthy shame, and the need for items (a) and (b) mentioned earlier.

Bibliography Creighton, M. R. (1990). Revisiting shame and guilt cultures: A forty-year pilgrimage. Ethos, 18, 279–307. Fung, H. (1999). Becoming a moral child: The socialization of shame among young Chinese children. Ethos, 27, 180–209. Kaufman, G. (1996). The psychology of shame: Theory and treatment of shame-based syndromes (2nd ed.). New York, NY: Springer. Kitayama, S. & Markus, H. R. (Eds.). (1994). Emotions and culture: Empirical studies of mutual influence. Washington, DC: American Psychology Association. Kobie, N. (2019). The complicated truth about China’s social credit system. Retrieved from https://www.wired.co.uk/article/china-social-credit-system-explained. Kostka, G. (2018). China’s social credit systems and public opinion: Explaining high levels of approval. Retrieved from https://papers.ssrn.com/sol3/papers.cfm? abstract_id=3215138. Lutz, C. A. (1988). Unnatural emotions: Everyday sentiments on a micronesial atoll and their challenge to Western Theory. Chicago, IL: University of Chicago Press. Miller, P. J., & Sperry, L. L. (1987). The socialization of anger and aggression. Merrill-Palmer Quarterly, 33, 1–31. Miller, P. J., Fung, H., & Mintz, J. (1996). Self-construction through narrative practice: A Chinese and American comparison of early socialization. Ethos, 24, 237–280. Oxford Economics. (2019). How robots change the world, what automation really means for jobs and productivity. Oxford, England: Oxford Economics. Schneider, C. D. (1977). Shame, exposure, and privacy. Boston, MA: Beacon. Schoenhals, M. (1993). The paradox of power in a People’s Republic of China middle school. Armonk, NY: Sharpe. White, G. M. (1994). Affecting culture: Emotion and morality in everyday life. In S. Kitayama & H. R. Markus (Eds.), Emotion and culture: Empirical studies of mutual influence (pp. 219–239). Washington, DC: American Psychological Association. Wilson, R. W. (1981). Moral behaviour in Chinese Society: A theoretical perspective. In R. W. Wilson, S. L. Greenblatt , & A. A. Wilson (Eds.), Moral behaviour in Chinese Society (pp. 117–136). New York, NY: Praeger.

Appendix Summary of 2018–2019 study and its quantitative results

The three quantitative surveys involved the participation of 42 Malaysian women of Chinese background following their perinatal losses in the last three years or less. Some other participant characteristics were also collected prior to the commencement of the surveys. Of the perinatal losses surveyed, 32 are miscarriages, 9 are stillbirths and 1 is a neonatal death. For the analysis, no distinction is made with regard to the difference in the type of perinatal loss. Indeed, Frazer and Cooper (2003), who investigated perinatal losses during different stages of pregnancy, averred that there is no significant difference in the grief responses of mothers losing a baby by miscarriage, stillbirth or neonatal death. This is also confirmed by a local study in Malaysia (n = 62) which found no significant relationship in the depressive state of mothers due to differences in foetal development following their perinatal losses (Sutan et al., 2010).

Participants The participants’ age ranged from 21 to 53 years (M = 32.3). The majority of them (85.7%) had at least a college-level education, with 19 having first degrees (45.2%), 13 having diplomas (31.0%) and 4 having postgraduate qualifications (9.5%). The main religions of most Chinese women in Malaysia are either Buddhism or Christianity. The majority (69.0%) declared that they have a religion while the remaining (31.0%) stated that they are without any religion. The majority of the women (76.2%) suffered the perinatal loss for the first time and the duration since their last perinatal loss up to the time they took the survey ranged from 0 month (three days) to 36 months (M = 16.9 months). Half of them had no children yet, while about a third of them already had one child. The overall characteristics of the sample are summarized in Table A.1.

Procedure Potential participants living in the Klang Valley of Peninsular Malaysia were sourced through referrals from friends, snowball referrals from the participants themselves, and Internet announcements such as the Facebook and personal websites. Initially, they were asked to fill out a Participant’s Particulars Form. If

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Appendix

Table A.1 Descriptive Statistics of the 42 Participants Variables

n or M

% or SD

Age (years) Education Elementary Secondary College/Diploma First Degree Postgraduate Religion With Religion (Buddhism/Christianity) Without Religion Time (months) between perinatal loss and taking the survey History of loss (number of perinatal losses at time of survey) First time Second time Third time Fourth time More than four times Number of Children at time of survey No child One child Two children Three children More than three children

32.30

5.69

0 6 13 19 4

0.0% 14.3% 31.0% 45.2% 9.5%

29 13 16.90

69.0% 31.0% 9.65

32 6 1 1 2

76.2% 14.2% 2.4% 2.4% 4.8%

21 13 7 0 1

50.0% 31.0% 16.7% 0.0% 2.4%

the person was found suitable, she was then asked to sign the Participant Consent Form, after which the researcher explained to her the purpose and nature of the three separate sets of self-report assessment questionnaires. The surveys took place at the first meeting between each participant and the researcher during the months from September 2018 to March 2019. All participants were assured of their anonymity and they are identified only as P01 to P42 with “P” standing for Participant.

Measures Shame. According to Viken, Hassel, Rugset, Johansen, and Moen (2010), the Internalized Shame Scale (ISS) is currently the most promising psychometric instrument for the empirical study of shame. The ISS is developed by David R. Cook (1994). He first used the ISS with alcoholics to empirically assess the level of shame in the individual to establish the impact on their recovery. The scale comprises a 30-item self-report questionnaire with 24 negatively worded items to measure intense affect and self-recognized shame and six positively worded selfesteem items, all on a 5-point Likert-type Scale of 0 to 4 (never, seldom, sometimes, often and almost always). In terms of Convergent and Discriminant Validity, ISS has modest, positive correlations between other measures of shame and guilt. Test-Retest correlations ranged from adequate (self-esteem: .69) to

Appendix 113 good (Shame: .84) for a 7-week time frame. For Internal Consistency, the ISS has excellent alpha coefficients (α) of .95 for a non-clinical study (N = 645) and .96 for a clinical study (N = 370), with .70 as the minimum. The lowest ISS score is 0, while the highest score is 96. The ISS scores of ≤49 represent low shame; 50 to 59 represent frequent experience of shame and ≥60 represent high shame. For this study, the ISS questions have been modified slightly by putting in the words, “Following the loss” to direct the participant’s attention to what she is experiencing following her perinatal loss, for example, “Following the loss, I feel like I am never quite good enough for anything”. The reliability analysis of the modified ISS questionnaire used in this survey demonstrated a very strong internal consistency for shame in the current sample (α = 0.97). Self-Esteem. This refers to the total score of the answers to 6 items on selfesteem in the same ISS questionnaire. The lowest score is 0, while the highest score is 24. The ISS scores of