Fall 08 Dell Children's Medical Center January 2015

Shame, Relevant Neurobiology, and Treatment Implications

Arlene Montgomery Ph.D., LCSW

Shame Guilt Early-forming (before age two) Must have concept of another (2 yrs+) Implicit memory (amygdala) Explicit memory (upper right & left hemi) Arousal involves entire body: Arousal is an upper cortex, primarily left, • excitement state of worry • painful arousal (SNS) • counter-regulate (PNS) • positive outcome = repair • negative outcome = no repair; lingering in PNS state Non-narrative (not conscious) Narrative (conscious experience) • a state of being: "I am something..." • "I did something" e.g., bad, worthless, flawed as a whole • an act person Runs away from further external Seeks to maintain attachments interactions, but cannot run away from the internal representations of the scorn of the other - an internal experience Shame states may engage the freeze Guilt experiences may engage the more (dissociated, passive) state or flight activated fight states ( not actually fighting, state(hiding, other avoidant behaviors) or but actively making thing right, correcting submit state(agreeing, becoming invisible, mistakes, engaging the milieu in some way complying) to manage the painful arousal to address the “bad act, moving toward…) Repaired shame is a normative socialization experience (Schore, 2003 a,b) Relational trauma may result from unrepaired shame experiences "corroded connections", (B. Brown, 2010); "affecting global sense of self" (Lewis, 1971)

Issues and Diagnoses PTSD: shame is predictor of posttraumatic symptoms (Herman, 2007) Suicidality: shame schema associated with higher levels of dissociation and correlated with self-reported suicidal risk variables (Young Schema Questionnaire, Young & Brown, 1999). Borderline Personality Disorder (deals with shame and guilt, but primarily shame) • Rusch, et al, 2007, (Experiential Shame Scale, Turner) found women with BPD score higher in shame and shame- proneness (at both implicit and explicit levels) than both women with social phobia and healthy women • In Kernberg’s (1975) work the ubiquitous use of projective identification addresses the object relationship (i.e., internalized self, internalized object [i.e., the other], and linking affect) to determine which elements or parts of the elements of the object relationship might be projected. Narcissistically injured people • Kohut (1978) & Morrison (1989) describe excitement and shame as including the somatic components of blushing & avoiding eye contact (both managed by PNS), and sweating & jitteriness (SNS) Addiction • (O’Connor & Weiss, 1993) use of shame and/or guilt to hold in place pathogenic belief that inhibits achieving normal developmental goals in order to maintain the tie to the necessary relationship; pain of shame/guilt states make vulnerable to drug use as pain management Couples • Other clinicians exploring the transference of affective states (aspects of shame and guilt) include Miehls (1997), Dicks (1993), and Middelberg (2001), whose work with couples has led them to identify the reciprocal feedback loop between partners and some common, often polarized, mental contents that may be split between the partners (e.g., the pursued–pursuer of Middleberg’s discussion).

Treatment Implications for addressing shame Call attention to noticed distinctive verbal, paralinguistic and nonverbal cues could alert to shame states (Herman, 2007) • Vocabulary of shame include, ridiculous, foolish, silly, idiotic, stupid, dumb, humiliated, disrespected, helpless, weak, inept, dependent, small, inferior, unworthy, worthless, trivial, shy, vulnerable uncomfortable, or embarrassed • Paralinguistic cues include confusion of thought, hesitation, soft speech, mumbling, silences, stammering, long pauses, rapid speech, or tensely laughed words • Nonverbal cues include hiding behavior, covering all or parts of the face, gaze aversion, eyes downcast or averted, hanging head, hunching shoulders, squirming, fidgeting, blushing, biting or licking lips, biting the tongue, false smiling (Retzinger, 1995 in Herman, 2007) B. Brown, like others, recommends shame and its triggers be recognized; practicing awareness; reaching out to shamed person; and speaking of shame (2012). These suggestions will regulate arousal which may persist in the implicit memory as an internal representation within the cortical & subcortical structures (Goldman-Rakic, 1987) Titrate addressing shame (Cloitre, Cohen, & Koenen (2006): to avoid reinforcing shame; striving for dignity rather than humiliated in the telling of experience of shame In dissociative disorders, shame itself is a shameful secret (Thurkus & Kahler, 2006)…psycho-education may help undo stigma and shame associated with being ill; patients on the trauma unit suggested to change the name to Psyche-education to move away from psycho, crazy, insane, etc. Transference: client expects to experience contempt, so not trust positive regard (Courtois, 1988) Counter-transference: shame, a contagious emotional with therapists uncomfortable leading to reluctance to directly confront own affects as well as client’s affects. Toxic affects (shame, guilt, envy, vulnerability, impotence, for example) may be attributed to the client via the therapist expressing sarcasm, teasing, ridiculing, and/or efforts to control the client in some way (Schore, 2003b, p.91). The therapist’s ability to recognize and regulate their bodily signals determines destructive or constructive counter- transference. Group work: emotional contagion may occur with exposure of the excitement of the shamed self-state which has preserved the grandiosity unmodulated in early dyadic experiences…sharing with others has potential to attenuate the pain of the oscillating arousal states (Nitsun, 2006, in Aledort, 2014); group work can address the power imbalance between client/therapist because of reciprocity, not so within dyad

Projective Identification Adaptive Defensive (maladaptive) • baby signals distress • same process as adaptive PI, but • caregiver has synchronous somatic maladaptive if used beyond young reaction adulthood • caregiver fixes the problem • brain attempts to offload • over time, baby retrieves comforting stressful/traumatic experiences (stored memories (hippocampus) in subcortical neural circuitry, out of • neuro-circuitry developing to comfort conscious awareness) self • Ridding the brain of an affect, etc., is • hippocampus and other memory not the same as signaling distress systems o not available for conscious o eventually are available to retrieval consciousness o disorganized o narrative line o chaotic o summary form

How does the ejected material actually "move" from one brain to another?

"Moving" = "signal distress" if adaptive "Moving" = "ridding/offloading" if maladaptive

Non-consciously, the projector chooses a vulnerable recipient The "sender" then treats the receiver in a way that causes him/her to experience what the projector is experiencing. This "offloading" is merely the sender's attribution of a trait, emotion, with, fear, etc., with which the "receiver" begins to resonate. In that moment, the receiver may have no idea of the origin of the affects. The sender can appear a bit blank (PNS) as if in a trance; if asked, the sender may appear bewildered because they are no longer experiencing the affect.

Transference and Counter-transference

The brain is associational, needing few cues to rapidly compare past experiences with elements of current perceptions. The brain uses a select sensory experience imprinted in the lower, subcortical regions, which are either - or in their associations involving safety and danger. If something is a little bit dangerous, the lower limbic system will experience huge danger. When Transference occurs, the client "relocates" a stressful or traumatic experience that happened in the past into the present, with the clinician.

Countertransference is the clinician's nonconscious reaction to the transferred experience of being with the client. There is a bodily experience in the clinician to the imagery, affects, or thoughts that have been induced nonconsciously by the client (involving the right amygdala and the right insula).

Neurobiology of Shame

Shame is biologically stressful, producing elevated cortisol and ACTH responses (stress management neurochemicals) {Herman, 2007} • shame transactions produce low levels of endorphins and corticotropin releasing factor (CRF) and elevated levels or corticosteroids • stress-induced adrenocortical steroids influence gene regulation and brain growth (Beato, et al, 1987, in Schore, 2003a, p. 21) • If this low affect state persists without interactive regulation over too long a time and too many times, this type of bio-regulation of arousal may persist in the implicit memory as an internal representation within the cortical & sub-cortical structures (Goldman –Rakic, 1987). • Shame is sub-cortical (right hemisphere) in origin, involving - among other structures - the right amygdala (safety-danger; fight, flight, freeze, submit; implicit memories; flashbacks; not conscious) and the right insula (mediates bodily states; resonating with emotional states of others) • The insula and amygdala have direct connections to ANS, the up/down arousal system affecting all organs and most glands of body.

The auto-regulation of the unrepaired shame-induced states heavily relies on dissociation, as the immature brain is bathed in the neurohormones and neurotransmitters that maintain the inhibitory state. • Little new learning or enjoyment can occur in this state of reduced brain development. • The gene activation induced by these environmental stressors can induce atrophy of certain limbic nuclei in the developing brain, resulting in social withdrawal and abnormal emotionality. • Paradoxically, low arousal, reflected in low resting heart rate, is a diagnostically specific early biological marker for later aggressive behavior…dissociation, the response to physical, sexual, as well as relational trauma is reflected in decreased heart rate. Low heart rate, found in no other psychiatric disorder, is also a marker of fearless behavior (Raine, et al, 1998). Such anti-social behaviors result from the seeking out of stimulation to increase arousal levels, often a reaction to small interpersonal stressors, especially if involving humiliation or perceived humiliation.

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