Chris L. Minnick, M.D.

Embarrassment, Shame, and Humiliation: Their Clinical Relevance

Disclaimer:
1 – This seminar represents Dr. Minnick’s personal experience with patients using Kleinian models of development in early infancy.

– A Kleinian orientation leads a therapist to nearly always look for the most intense emotional state that is having the greatest impact on the patient at that moment. The most intense emotions are usually emanating from the baby core of the personality unless the external reality situation is realistically intensely upsetting.
Even then, such an upsetting situation will activate the most intense and profound baby level feelings and phantasies that parallel the external situation. If the external situation cannot be dealt with in a constructive manner, baby level issues will always be found at the root of the failure to cope constructively.

2 – With this orientation toward primitive mental states, shame will not be a primary emotional state that will be a center piece of the therapy. That is not to say that it doesn’t play a very pivotal role in the psychology of some patients.

3 – Self Psychology uses a fairly different set of assumptions and models about development in infancy which make “shame dynamics” considerably more prominent. [See Melvin R. Lansky, M.D. for 20+ years on shame.]

Overview:
1 – These emotions all have their origins later in infancy, probably somewhere in the second year of life.

2 – These emotions require a sense of separateness from mom, an awareness of a developing capacity for independent function, a desire to no longer be a baby, and a wish to keep some things private, i.e. hidden from the view of others.

3 – The definitions of these words are to a certain degree arbitrary. Common usage has some tendency to substitute a word which is unconsciously undesirable for one that is more acceptable, in a manner analogous to the substitution of jealousy, which is linked to love, in place of envy which is more linked to the less desirable emotion of hatred.

With this unconscious reaction in mind, my observation of common usage is that embarrassment is often experienced as less “bad” than shame, which in turn is less “bad” than humiliation. When the more undesirable word would have been applicable, people will add a modifier like “totally” to increase the severity of the more desirable word, as in “He was totally embarrassed by the opponent..” when they might have said “He was humiliated by the opponent.”

4 – Throughout this course, all states of mind which are described as being in response to an interaction with someone in the outside world can potentially take place in an analogous fashion completely within the unconscious inner world. That is to say that they would take place between a part of self and an internal version of mom or dad, etc.

Axiomatic Ideas:
Axiom #1: The degree to which infancy, and any qualities linked to it, is disliked or even hated, the more susceptible the individual will potentially be to having embarrassment, shame, and/or humiliation.

Axiom #2: In childhoods in which caregivers and/or siblings/peers were hostile, mocking, or cruel in any consistent manner regarding being small, helpless, dependent, etc., the susceptibility to feeling humiliated significantly increases.

Axiom #3: While cruel behavior from the environment will commonly intensify these emotions, it is possible for a person to generate these feelings on their own without any significant mistreatment in early childhood. All that is required is a feeling that being small or dependent is undesirable, followed by a projection of that attitude into the environment.

Axiom #4: The unconscious use of grandiosity and omnipotence, to defend against feeling small or dependent, greatly increases the susceptibility to these three emotions.

Axiom #5: Where unconscious envy is prominent in a patient, shame and humiliation are very likely to be more prominent in that individual. In effect the envious person lives in an inner world where baby states of mind or qualities of behavior are hated, are projected when experienced in self, are viewed with scorn and contempt in others, and these maneuvers and attitudes become the “coin of the realm”.

Definitions of These Three Emotions:
1 – Embarrassment: It involves self-consciousness because something has become visible or apparent to others that one would not ordinarily want to be seen or known, i.e. it is private. This exposure may be abrupt and one is often caught off guard. The resultant emotional state may be distressing, confusing, and put one ill at ease, commonly leading to a loss of composure.
– e.g. walking in public , stubbing one’s toe on the sidewalk, and falling down

– e.g. having one’s fly unzipped; having the top or bottom of a swimsuit slip down or come off; passing gas

2 – Shame: Originally, a painful feeling in early childhood that one has acted less than one’s age and therefore has lost the respect of others and/or oneself. Later it can extend to a feeling of having lost the respect of others because of improper behavior, incompetence, etc. It can have a moral undertone.
– e.g. pooping or peeing in one’s pants, (e.g. diarrhea, laughing, a “wet” fart w/ a bad odor, etc.)

– e.g. getting drunk and throwing up on someone’s carpet, in their car, etc.

– e.g. making a politically incorrect comment that is overheard because one’s microphone is on

– e.g. being caught taking drugs or having an affair when in the public eye

3 – Humiliation: Essentially an extension of shame, but with an emphasis on an individual, external to the self, viewing the loss of stature with triumphant hostility. This pleasure in the pain of the other adds an air of cruelty to humiliation on the part of the viewer toward the fallen individual.
– e.g. having your spouse yell at you and say derogatory things at a dinner party

– e.g. having your mother tell your teenage friends to go home when you are having a slumber party

– e.g. losing a football game by 63 to zero, getting knocked out in the first minute of the first round, etc.

– e.g. being accused of an act that knocks that person off an idealized pedestal, exposes hypocrisy, etc.

[Note: Any omnipotent, grandiose element in the personality that elevates one relative to others increases the risk of falling off that elevated pedestal. In other words, omnipotence and grandiosity as character features in a given person increase their susceptibility to humiliation. In turn, this demonstrates the degree to which humiliation has a link to unconscious envy via the arrogance and grandiosity that envious competitiveness often generates. Previous sanctimony and sitting in judgment of others adds to the severity of the humiliation because there is farther to fall and a greater paranoid expectation of hostile retaliation for the hypocrisy. ]

Qualitative Differences Between Embarrassment, Shame, and Humiliation:
1 – Embarrassment emphasizes having something seen that would ordinarily be kept private. It is often generated by accident and does not necessarily imply that anything has been done “wrong” by the person feeling embarrassed.

2 – Shame has a greater emphasis on not living up to one’s age or expectations. The result is a recreation of the painful baby feeling of being small, incompetent, helpless, dependent, etc. It may appear to be generated by the outside world seeing this state but it actually implies that the person themselves harbors a disapproval as well.

– As Eleanor Roosevelt said: “No one can make you feel inferior without your consent.”

3 – Humiliation emphasizes that someone else is watching and is wishing to inflict pain by causing the victim to feel small, defeated, at fault, exposed, etc. It suggests cruelty, i.e. taking pleasure in the wish to inflict pain, as a motive in the other.

The Spectrum of Severity of the Reaction with Each Emotion:
1 – Since these spectrums are dependent on the definition given to each word, and many of the differences are subtle and variable, these spectrums are very arbitrary. They are meant to aid exploration, not to be taken concretely as fact.

2 – Embarrassment spectrum: self-conscious < indecent < blushing < disconcerted < mortified

3 – Shame spectrum: awkward < ignominious < improper < unchaste < ashamed < disgraced < dishonored < scorned < worthless < contemptible

4 – Humiliation spectrum: sensitive < vulnerable < thin-skinned < demeaned < belittled < slandered < debased < defiled < disfigured < demoted < degraded < humiliated

Why Isn’t Shame in the Kleinian Literature?
1 – If one sees ES&H as emotional components of the second year of life, then the early super-ego, unconscious envy, projective process, the defensive elements that will underlay psychic retreats, etc. all have an origin in the first year of life and will therefore precede ES&H in the vast majority of situations.

2 – Interestingly, in early life, perhaps most of the first year, the child seems to be insensitive to embarrassment and shame, as commonly seen regarding nudity and toilet functions.

– This changes in the beginning of the second year as embarrassment begins to emerge like a movement out of paradise. This is perhaps linked to a developmental increase in awareness of separateness as motor activities and frontal lobe development lead to fewer and shorter episodes of feeling fused and/or inside one’s objects

3 – The Kleinian dictum of looking for the maximal anxiety or emotional pain would take one to unconscious phantasies that underlay the hatred of baby states.

– In the case of shame, the feeling of shame would tend to be seen as a signal or manifestation that there is an underlying emotional state or phantasy that is seen as more primary than the shame.

– In the case of humiliation, there would be an implied hatred of baby states of mind in someone in the outside world who then cruelly projects those unwanted states of mind into the baby or child. The focus would then be on the projector’s cruelty and the resultant impact on the recipient of the projections.

Expressions in Myth and Fairy Tales:
1 – Small children’s nursery rhymes:

– “Humpty Dumpty sat on a wall, Humpty Dumpty had a great fall, all the King’s horses and all the King’s men, couldn’t put Humpty Dumpty back together again.”

– “The Incy Winsy spider went up the water spout, down came the rain and washed the spider out, out came the sun and dried up all the rain, and the incy winsy spider went up the spout again.”

– I have never felt that I exactly understood why these are told to small children. I have a very strong suspicion that they are both describing birth, the first with a resultant feeling of catastrophic hopelessness, and the second offering a chance to be “unborn”, as needed.

2 – Icarus of Greek Mythology: The son of master a craftsman named Daedalus, Icarus is described as wishing to escape from Crete with his father on wings crafted by his father out of feathers and wax. He and his father took off together after his father admonished him to follow him and not to fly too close to the sun. Icarus, however, giddy with being able to fly, becomes too adventurous, gets too near the sun, the wax melts, the feathers fall off, and although he keeps flapping his arms, he falls to the sea and drowns.

– This myth is commonly taken as an example of hubris or failed ambition.

– From a more psychoanalytic frame of reference, there is an oedipal quality of omnipotently taking possession of daddy’s penis, and then arrogantly asserting that one has become the same as dad and can approach mother’s body to possess it. From this point of view, it is analogous to Sophocles Oedipus story.

3 – The Emperor’s New Clothes: An Emperor is only interested in showing off his new clothes which he is constantly acquiring. Two imposters arrive claiming to be weavers capable of making the most beautiful cloth imaginable. The cloth has this magical property of being invisible to anyone “not fit for his office” or “unpardonably stupid”. While pocketing money and fine silk, the imposters have nothing on their two weaving-looms. The Emperor sends wise ministers and statesmen who, not wanting to appear unfit or stupid, repeated what the imposters tell them about the cloth they could not in fact see. When the Emperor finally has a procession in front of the town’s people, an innocent boy says “But he has nothing on!”

– This story by Hans Christian Anderson seems to emphasize the impact of narcissism and environmental/cultural influence on the emotions of ES&H.

– Note that if one identifies with the nakedness of the Emperor, one might feel embarrassed for him. If on the other hand one projects one’s own unwanted arrogance while simultaneously feeling envious of his status, then one may feel contempt for him and believe he has been humiliated, i.e. brought back to his original undesirable “baby status” that he tried to cover up with his preoccupation with fine clothing.

4 – The Garden of Eden Biblical Story: In Eden (Aramaic for “fruitful, well-watered”) God places a man to tend the garden but forbids him to eat from the “tree of knowledge of good and evil” and then forms a woman from his rib to keep him company. The first man and woman break God’s command, eat the fruit from the forbidden tree, and God expels them from the garden to keep them from eating from the second tree, the “tree of life” and then living forever.

– This myth can be taken in many ways. For this course it is useful to consider the infantile fantasy that the parents have magic and other possessions which the infant would like to possess himself/herself. The parent/God, fearing this envious intrusion and theft, expels the naked baby, leaving it in a diminished state.

5 – Snow White and the Seven Dwarfs: A very envious Queen wants to be the “fairest of them all” so she has her stepdaughter taken to be killed by her huntsman when the girl grows up to be more beautiful. The huntsman takes pity on her, leaves her in the woods, where she is discovered and taken in by seven dwarves, Bashful, Doc, Dopey, Grumpy, Happy, Sleepy, and Sneezy. When the Queen discovers SW is still alive, she makes a poisoned apple which she gives to SW claiming it is a “magic apple” that will help her find true love. SW falls into a death-like sleep, but is not buried because the Dwarves cannot bear to lose her. A Prince comes along, and saves SW because the evil spell could only be reversed by “loves first kiss”.

– While this is a fairy tale that can be given many different meanings depending on which aspect is highlighted, extreme idealization of early infancy, as a result of splitting off destructive urges (born out of envious hatred) and projecting them, is one useful component interpretation. In the story, the Queen is ultimately chased to a mountain precipice from which she falls to her death, certainly an extreme depiction of the problems of envious narcissism and the grandiose positions it can lead one to take.

Prototypic Situations of Embarrassment, Shame, and Humiliation in Early Childhood:
1 – The “expressive” use of language tends to be adequate for to and fro communication around the middle of the second year of life. The infant has more capacity for the understanding language prior to that but not an equivalent capacity to elaborate on its states of mind. It still tends to rely on “song and dance” and the word “no” prior to the middle of the second year. As a result of this discrepancy, the states of mind attendant to ES&H are more inferred in the toddler than clearly elaborated through words.

– e.g. a child insists on feeding itself: e.g. insisting food be put on the highchair tray; insisting on holding the bottle or “sippy” cup or spoon, no matter how inadequately performed; etc.

– e.g. a baby hates having its diaper changed

– e.g. a toddler refuses to crawl, insisting on being picked up

– e.g. a toddler refuses to try to walk or gets furious when it falls despite the parents’ encouragement

2 – There are situations where the small child apprehends that the parent’s response to the child is negative in some way. That has the potential to intensify that child’s unique reaction to the situation, for example feeling responsible for something bad, feeling blamed, bad, unlovable, unwanted, etc.
– e.g. the mother is ill or depressed

– e.g. the parents are ambivalent about the child’s existence in their lives

– e.g. the parent, often psychotic, who tries to initiate “toilet training” in the first year of life

– e.g. the child is put up for adoption, born prematurely, mother goes back to work, etc.

3 – Family situations in which parents or siblings are overtly hostile or cruel to the infant or toddler greatly increase the likelihood of the child having a negative reaction to elements of its own status in the family.

4 – Unconscious envy can compound all of the above.

<u>Case Example</u>: [See last section of this course.]

The Problem of Distinguishing the Origin of Attitudes About Oneself:
1 – A toddler or child may have attitudes about its status as a child or baby that is a product of (1) its own attitude about being a baby, (2) its parents attitudes about being a baby, (3) its attitudes toward the parents (which alters the child’s view of how the parents feel back toward the child), or any combination of the three.

2 – Attitudes about being an infant (i.e. attitudes as children toward themselves originally, and later as adults):
– some people embrace dependency and some abhor it

– some people compete with ferocity and some completely eshew competition

– some people are tremendously self-aggrandizing and some are modest to a fault (this includes those who are delusional in overestimating their abilities and those in denial of their true capacity)

In summary, some people feel that being a baby is a state of horrible inferiority and view it with contempt. Others feel it is simply a necessary phase of moving on to becoming bigger and more capable, i.e. a perfectly acceptable period of growth and development with lots of interesting adventures along the way.

3 – Attitudes and treatment by parents of their children:
– loving, nurturing, accepting versus neglectful, impatient, resentful of the child’s existence and needs

– separate, encouraging, patiently educational versus projecting unwanted infantile parts of self into the child leading to fusion, or its opposite, rejection (often determined by whether the “center of gravity” of the sense of identity goes with the projected “baby part” or stays within the projector)

– lovingly setting boundaries and appropriately modulating youthful exuberance or grandiosity versus angrily, cruelly, or gratuitously being demeaning, rejecting, or punitive including emotional and physical violence

In summary, some parents find parenthood a hideous burden that reminds them of their own hated past and smallness, while interfering with having a life, in contrast to others who feel the sacrifices are worth it to bring a happy new life into being, and perhaps making up for some of what they did not get in their own childhood.

4 – Attitudes of children toward their parents:
– confident expectation of love, encouragement, and safety versus anxiety, doubt, and fear

– idealization of parents versus disapproval, disappointment, and/or contempt

– love and gratitude versus manic denial of goodness received, envious resentment, hatred, and rage
In summary, where the relationship between child and parent is satisfactory, and the child is not excessively enviously resentful of the parents capacities, etc., the parents will usually be idealized to some variable degree and be seen as positive figures overall who are loved. On the other hand, if the child has an excessively intense envious reaction to the parents, then it is more likely to focus on the parents’ inevitable failings, handicaps, etc. with an uncharitable “eye” toward criticism and even contempt. This will greatly increase the expectation of being “eyed” in the same hostile manner back for anything done wrong by the child.

5 – Conclusion: When looking at a human’s original attitude toward its status in the world as an infant, toddler, or child, it is typically very difficult to sort out the relative contribution of parental attitudes and behavior versus the child’s very own attitudes about its position in the family and life. It can be said that where there is a congruence involving the child’s attitude about smallness, being helpless, inadequate, needy, dependent, etc. and the parent’s attitudes about those issues, the child’s attitudes will be strongly reinforced.

Unconscious envy in the child toward the parent is perhaps the one crucial variable that can alter the situation and lead to a seemingly paradoxical attitude toward ES&H. In effect, the child’s attitude may not follow the seemingly expectable, logical outcome that would have been predicted using the parent’s attitudes and behavior as the primary determining variable.

Put in other words, it is possible for unconscious envy, when intense, to override the impact of what might otherwise appear to be very desirable attitudes and behavior from the parents that should not have generated in the child such intense feelings of ES&H.

Another way of saying all of this is that the “internal versions of the parents” (i.e. the “super-ego”) may be fairly different from the actual external parents. As a result, all therapists must take with a grain of salt what the patient says the parent, spouse, boss at work, etc. was like in the past. The therapist must “take in” the patient’s view of the figure but keep in mind the potential for distortion based on projections into the object.

The Formation of the Super-Ego and Its Relationship to ES&H:
1 – If one makes the assumption, as I do, that humans are phylogenetically predisposed to expect there to be a mother figure and a father figure in the world into which they are born (i.e. “preconceptions” of each), then it easier to see that internal versions of them will be created based on the combination of experience with them, and one’s unique perception of those experiences with each parent. Envy, jealously, unexpected events before and after birth, sibling number and spacing, etc. can have profound and potentially distorting influences on what sorts of versions of mom and dad are created internally. These influences can be so powerful that the internal version may only minimally correspond to the actual parents, a truly daunting reality for parents with best intentions at heart.

– Profound emotional experiences in infancy (e.g. prematurity, a traumatic birth, being given up for adoption, sibling’s spaced less than two years apart, colic, illness, parental separation or loss, etc.) will have a great determinative impact on the creation of internal versions of mom or dad. In such situations, these “internalized” versions of the caregivers may even be quite a bit more “fantastic” than the actual parents. This is particularly true of prematurity and adoption which are so profound and occur so early in infancy and are stored at a midbrain level and reworked for years thereafter. Intense colic in the first three months of life may also have such an impact. In all three situations the internalized versions of the parents are often quite different from the actual external ones.

On the other hand, highly repetitive experiences of parental behavior that is either positive or negative can have the same formative impact, more based on repetition than based on emotional profundity. These can also lead to rather fantastic versions of mom or dad but it is common for these internal versions to have more apparent correspondence to the real external figures.

2 – Children can be seen to have various consistent patterns of feeling and behaving that come to represent distinct aspects of themselves, experienced as distinct “parts of self”, often held very separately in the child’s personality and mind. Some may be “split off” most of the time, only to come home to roost when the child is tired or provoked in some specific way. An especially jealous, envious, mean, sad, or even crazy aspect/part of self may only be seen sporadically in fairly specific situations for seemingly no obvious or predictable reason.

3 – The result of the child’s experiences of parental figures leads to a theoretical bare minimum set of possible versions of mom and dad in the unconscious inner world. These would include a good mom or dad and a bad mom or dad, resulting in a total of four versions of mom and dad. In a manner analogous to parts of self, some of these versions of mom or dad may be “split-off” and held very separately in the child’s unconscious inner world.

4 – The various consistently seen aspects/parts of self are inherently and inevitable found to be paired with very specific versions of mom or dad. These pairings are typically the result of the child’s consistent reaction to specific childhood situations that were either profoundly impactful on one occasion, or were repeated many times in the child’s experience.

Put in slightly different words, the unconscious inner world seems to become populated by emotionally significant experiences during which a part of self and version of mom or dad were felt to be doing something to or with each other for some specific reason. It is the emotional context/situation that “pairs” the self and object together and generates neuronal patterns that are stored in the brain at various levels. The “meaning” given to these pairings can be elaborated and reworked during later infancy and childhood, sometimes making it more realistic, but often just cementing a distorted version of “who is doing what, to whom, and why”.

5 – The primary reason for emphasizing the internal versions of mom and dad is to create an awareness that ES&H can arise almost entirely from internal sources, in some situations, and therefore have far less correspondence to the outside world than common sense would suggest.

– For example, a child could have parents that would never tease or shame the child and yet the child can feel that it is being viewed and treated with an eye toward embarrassing, shaming or humiliating it. This is, for example, an almost a universal attitude in adolescents toward their parent’s behavior.

Omnipotence and Unconscious Envy in Relation to ES&H:
1 – If one has relied on omnipotent grandiosity to cope with painful feelings of being small or inferior, then giving it up will be greatly feared as exposing one to a great fall. Just ask “Humpty Dumpty”.

2 – It is important to remember that envy is a universal, intensely painful emotion that is inherently embedded in earliest infancy as a result of the enormous discrepancy between the capacities of the mother and the infant. It seems to vary in intensity as a result of biological predisposition and is definitely exacerbated by environmental inadequacy or hostility.

– When envious hostility is directed at one’s objects on a consistent basis in infancy and early childhood, the expectation of retaliation and hostility back greatly intensifies the predisposition to shame and the expectation of humiliation piled on top of the shame. Projection of this hated baby state of being adds to the paranoid expectation of retaliation.

Projective Processes and These Three Emotions:
1 – It is important to note that all three of these emotions suggest the presence of a second person who is viewing/seeing something. The person being “viewed” is having an emotional reaction to “being seen”. The meaning of the fact of being seen is then a product of the emotional reactions of both individuals who are involved.

Either of the individuals involved may react emotionally in a manner that that can exist on several continuums.

– The reactions may be realistic and adult, or unrealistic and infantile.

– The reactions may be loving and supportive or hostile and cruel.

– The individual having the reactions may stay psychologically separate or either/both may immediately project into one another and distort their boundaries in relation to each other.

2 – Embarrassment is the emotion that is the least necessarily linked to projective processes. In other words, the embarrassed individual need not attribute anything to a viewer.

3 – Shame is most open to confusion about who is doing what to whom and why. It often requires some detailed exploration to sort out whether the person experiencing the shame is recreating their own internal situation, the viewers reaction, or whether the situation would have shame as a reasonably expectable response.

4 – Situations involving the experience of humiliation are the most likely to involve relatively clear cut projections from the viewer into the person viewed and feeling humiliated.

Embarrassment, Shame and Humiliation in the Therapeutic Relationship, General Issues:
1 – It is quite common for a patient to come into treatment with deep, pervasive confusions as to what represents “adult” attitudes and behavior versus “infantile” ones. In the Kleinian literature, this confusion was originally commonly referred to as “faulty horizontal splitting”, implying that the individual had confusion about adult versus infantile elements in life.

A common example would be the mistaken equation of physical size with emotional maturity, as if to imply that a person who is physically “grown-up” has therefore also achieved a level of maturity at an emotional level that experience tells us is often not the case, as is so in evident in mid or late adolescence.

2 – One of the tasks, often quite prominent in the early years of analytic treatment, is the gradual recognition of and working through these sorts of confusions.

– e.g. confusion of size, material possessions, wealth, power, etc. with maturity

– e.g. confusion of independence, self-reliance, invulnerability to emotional pain, etc. with desirable achievements linked to mature emotional capacities and mental health

– e.g. confusing “addictive dependence” (which is “anti” growth) with healthy reliance on and need of the analyst/therapist (which is necessary to promote growth)

– e.g. confusion of a capacity to dominate, control, intimidate, etc. with earning or deserving respect (parents cannot demand the respect of their children, they have to earn it)

ES&H in the Therapeutic Relationship as a Result of “Psychic Retreats” [John Steiner]:
1 – A “psychic retreat”, as developed by the English Kleinian psychoanalyst John Steiner, refers to a defensive organization that is used by a person to avoid anxiety and emotional suffering. It represents that person’s set of consistently used unconscious defensive maneuvers and attitudes. Any disruption of those maneuvers leaves the patient feeling “naked and exposed”.
– e.g. feeling expelled from the Garden of Eden and feeling shame
– e.g. having a large falling back to earth and reality when grandiosely overreaching to the Sun
– e.g. being exposed as “stupid” and “unfit” when one’s cloak of fancy clothes is removed (protective clothing of the retreat)

2 – A “narcissistic type of object relationship” is the most common form of psychic retreat and has powerful unconscious envy at its root. In this type of relationship the good qualities of the object are appropriated while the hated and unwanted “bad” aspects of self are projected into the object (i.e. creating a role reversal).

– Because this reversal makes one “bigger” than one actually is, having this self-idealization and aggrandizement be seen can be intensely humiliating.

– ES&H are all so painful that, in a manner analogous to the defenses against awareness of envy, they to seem to demand immediate relief from the feelings of inferiority and feeling viewed with contempt, being looked down on, and feeling ridiculed.

3 – The psychic retreat requires that some aspects of the reality of self or object be “split off” and/or denied, because if these elements were seen and acknowledged, they would lead to mental pain. This in turn distorts the perception of self and object meaning that neither is seen in a clear, realistic manner. Projections into the object further distort these perceptions. The distortions often involve self-idealization and aggrandizement.

4 – Therefore, coming out of the retreat as a result of analytic work on it exposes the patient to the painful feelings of envy, jealousy, frustration, rage, guilt, remorse, etc. that had been previously hidden from sight.

5 – Periods of constructive growth and movement in therapy into the depressive position by definition require that the patient be more psychologically “separate” and face their treatment of their objects. This can expose the patient to very painful states of shame, etc. because of the resultant recognition that they have behaved badly, cruelly, crazily, etc.

– The patient must face the collapse of “self-admiration and narcissistic pride”. With the resultant exposure to ES&H, the patient may become highly persecuted and paranoid or alternately retreat back to the previous defensive enclave.

– If the person stays in contact with their treatment of their objects, then they have the problem of facing intense guilt as well.

6 – There is the potential, as the patient is more separate and sees how they have behaved, that “being observed” accrues a particular quality of cruelty and pain where the observer is felt to be hostile, attacking with a goal of removing the patient’s narcissistic state and make them feel especially inferior and humiliated.

– Therapy can stall at this point or even reach an impasse [See Herbert Rosenfeld’s book “Impasse and Interpretation”]

Implications for the Therapist:
1 – It is necessary for the therapist to be aware of and sensitive to the pain the patient feels as they face their omnipotent, defensive maneuvers and their past treatment of their “good objects”.

– Because narcissistic patients are particularly sensitive to “status” and unconsciously fear having their superiority challenged and fear finding themselves being “looked down on”, some patients will treat all interpretations of their infantile states of mind as a purposeful “put down”.

2 – It is useful to make clear the historical string of emotional reactions, showing the logical link between the earlier feelings and defensive maneuvers, and their later emotional consequences and evolutions. In other words, the patient is then able to see that maneuvers once needed for survival are no longer needed, but their original use was the best one could do and is human, not morally reprehensible.

– This carries an implication that the patient who is particularly shame based in their view of life need not feel such intense shame and humiliation now as an “adult” reaction to their current life. In effect, the ES&H that they continue to expect to feel are now anachronistically out of date.

Countertransference Difficulties in the Therapist:
1 – Attitudes of “sitting in judgment”, as a tendency in the therapist, will greatly intensify the patient’s realistic feeling of being viewed with contempt or cruelty with a motive of inflicting shame and/or humiliation.

– IT IS NEVER THE THERAPIST’S JOB TO BE MORALISTIC!

2 – Some patient’s provoke contempt through their behavior or projections. The therapist must distinguish his or her personal reaction to the patient from the patient projecting a “shaming” reaction into the therapist as part of the repetition compulsion. In the latter, the patient could be projecting either a baby part of self that feels ashamed, or an internal version of mom or dad that is felt to be shaming.

3 – It is important for therapists to help patients see their distortions of their parents based on the infant’s or child’s projections into the parent.

– Remember that one of the greatest problems that results from having disturbed, abusive, or crazy parents is that it is more difficult to see and take back one’s projections into them of unwanted parts of self. This is true not only for patient’s, but also for the therapist of those same patients. In effect, therapist and patient can enter into a “folie au deux” in which they both project into the patient’s parents.

– One of the most obvious ways to see these distortions of the parents, based on projection, is that those same projections will occur in the transference and distort the patient’s perception and experience of the therapist.

4 – The therapist can benefit from an awareness that the models they use for understanding the patient may feel inherently aimed at shaming the patient, feeling superior, etc. This may require the therapist to go much more slowly with interpretations than they are used to, modifying the words they use, etc.

– Some patients are so concrete, project baby states of mind immediately when experienced, and feel so expecting of criticism, that anything the analyst describes that seems undesirable or childish will be experienced as a hostile attack on them.

5 – The take home lesson is that our work as “headshrinkers” is hard to do, and is hard to receive. It naturally has an undertone of shaming and humiliating the recipient. Therefore, the more models the therapist has for understanding these possibilities, the more likely he/she will deal with them empathically, effectively and constructively.

Case Example
Background:
A male in his mid-forties, with a high achieving professional career, came to treatment because of a lifelong paralyzing inability to be in public situations in which he feared he might have to abruptly go to the bathroom (i.e. possibly have diarrhea) or become nauseated (i.e. throw up). This limited his ability to be in a car with someone else driving, sit in a movie where he was not on the isle seat, go on any type of boating situation, go out to do anything with anyone if he had a mildly upset stomach that day, etc.
He had been briefly married in his twenties to a woman who was intelligent, very attractive, but very “private”, completely career oriented, and abruptly told him about a year into their marriage that she no longer wanted to be married. They divorced without much fanfare and he never understood what happened.

Early History:
The patient was the second born of three children, all born roughly two years apart, to parents who were both “academics”, the father in applied sciences and the mother in liberal arts. The patient felt consciously that he was close to his mother but distant from his rather perfectionistic and judgmental father.

Upon deeper inspection I felt that he was not in fact close to either parent. I thought he confused praise from his mother for his high achievement in school with actual emotional involvement, a capacity for which I felt his mother was lacking. His father was remote, narcissistic, critical, held grudges for perceived injuries from relatives and colleagues, and was generally feared by the patient as I experienced it.

The patient’s infancy turned out to have gotten off to a poor start. Early in treatment I asked him to inquire how his infancy had gone as he could remember almost nothing before first grade. His mother then told him that he was a “difficult” baby, that she had tried to breast feed him for two weeks but had to stop and switch to the bottle (for some vague reason that she never explained in a fashion that I could make sense of based on what she told him).

[My reconstruction during the treatment was that she wanted a “perfect baby” that made no demands of her that were not in complete synchrony with whatever her desires were at that moment. I felt he had recreated that situation in his “ideal”, but brief marriage that ended abruptly, with no apparent explanation.]

His only actual recollection of a formative experience was his first day of first grade when a girl sat two rows over from him and shortly after class started “threw up on the desk”. She was taken out of the class and he did not recall if he ever saw her again. My take was that she was terrible anxious. Interestingly, his ultimate take home lesson, probably reworked over the years, was that she had done something terribly unacceptable and had been “removed” from the class for it.

Transference Behavior:
As he had been in childhood, the patient was clearly keen on being a very “good” patient, not in the sense of cooperation and developing insight, but in a more shallow concrete sense of being proper, likeable, and not being a problem for me. He was hypersensitive to any hint that I might be critical or disapproving.