This document summarizes research on shame and its relationship to various mental health conditions. It begins by defining shame and differentiating it from guilt. It describes shame as a secondary, self-conscious emotion that is related to failures in social connection and conformity. The document then discusses research showing that shame is elevated in conditions like schizophrenia, dissociative identity disorder, and following traumatic experiences. Shame is also linked to increased criticism from family members of people with schizophrenia and greater relationship problems for those with dissociative experiences or higher levels of shame. Overall, the summary highlights how shame is an important emotion to consider in understanding and treating various mental health problems.

1. Martin J Dorahy
Department of Psychology
University of Canterbury
New Zealand
“I did not fear punishment,
but I dreaded shame. I felt
no dread but that of being
detected”
(J. J. Rousseau, 1782 )

2. Shame
 “In the gaps and clumsy steps in human intercourse, in the
misunderstandings, the misperceptions, and misjudgements, in the blank
mocking eyes where empathy should be, in the look of disgust where a
smile was anticipated, in the loneliness and disappointment of
inarticulate desire that cannot be communicated because the words
cannot be found, in the terrible hopeless absence when human
connection fails, and in the empty yet rage-filled desolation of abuse-
there in these holes and missing bits lies shame. Shame is where we fail.
And the most fundamental failure is the failure to connect with other
human beings—originally the mother” (Mollon, 2006, p. xi).

3. Primary and secondary Emotions
Primary emotions Secondary (self
conscious) emotions
Very early
(0-9 m),
require no SC
Present later
(18-24 m),
require SC
Joy
Distress
Anger
Fear
Disgust
Surprise
Shame
Guilt
Pride
Embarrassment
Lewis, 1992; Tracy & Robins, 2007
Self-awareness; self-rep.
Emerge later
Facilitate social goals
No universal
facial expressions
More cog. complex

4. Shame
(affect)
Motive
Restore
positive self-
view
Protect
Injured self-
view (from
further
harm)
Competence
restoring positive
self view
high
Low
Approach/repair/r
epeat
(behaviour)
Avoid/withdraw/h
ide
(behaviour)
De Hooge et al, 2010

5. Adaptive aspects
 Efforts to avoid shame activation can:
 Increase pro-social behaviour (e.g., Scheff, 1997)
 Reduce damage to social status (e.g., Gilbert, 1998)

7. Effects of shame on the person
 Shame
 influences vulnerability to mental health problems
 Affects expression of symptoms,
 Affects abilities to reveal painful information,
 Associated with various forms of avoidance (e.g.,
dissociation and denial)
 Creates problems in help seeking
• (Gilbert & Procter, 2006, p. 353; Hook & Andrews, 2005)

8. “Shame operates everywhere in therapy
cause clients are constantly concerned
about what part of their inner experience
can be revealed and what parts must be
hidden”
Greenberg & Paivio, 1997, p. 235

9. Why focus on shame in therapy
 “Overwhelming feelings of shame may contribute to
early treatment drop-out or indeed may be the
reason why some individuals never present for
treatment in spite of suffering from debilitating
symptoms…” (Lee et al., 2001, p. 464)
 Has implications for all stages of treatment
(Herman, 2011), including the therapeutic alliance

10. Risks for therapy in overlooking
shame
 Shame impedes social connection (‘severs interpersonal
connection’ – Kluft, 2007), and therefore impedes the
soothing and emotional regulation that comes from
others (Hahn, 2009). Thus, the presence of shame will
strongly influence the degree to which the therapeutic
relationship can be seen as safe and be utilized to bring
about progress.

11. Impact of shame therapeutically
 Shame will undermine exposure work/trauma
processing (e.g., narrative work, CBT, EMDR,
rescripting) (Blum, 2008, Kluft, 2007; Lee et al., 2001).
 Will have likely implications for relapse if not
addressed

12. Why focus on shame and guilt in
trauma? (cont.)
 Is linked to more overt symptomatology such as
depression, PTSD avoidance, dissociation,
stigmatisation

14. Shame defined
 “Shame can be defined simply as the feeling we have
when we evaluate our actions, feelings, or behavior,
and conclude that we have done wrong. It
encompasses the whole of ourselves; it generates a
wish to hide, to disappear or even to die” (Lewis, 1992,
p. 2)
 Shame is the affect of inferiority (Kaufman, 1989)
 SHAME IS RELATED TO THE SELF
 Repair behaviours designed to repair self-view

15. What is shame?
 “A complex and disorganizing experience dominated
by painful emotions, obsessive rumination, and
condemning imagery. Feelings of inadequacy and
worthlessness are accompanied by tormenting and
accusatory thoughts and an excruciating sense of
aloneness” (Hahn, 2009, p. 303)

16. Shame and relationships
 Shame is inextricably linked to emotional
relationships.
 Emotionally significant relationships play a central
role in the etiology, development, and expression of
shame
 Hahn, 2009

17. 4 shame phases: Nathanson (1992)
 Four phases of shame:
 Trigger
 Physiological/affective reactions
 Cognitive reactions
 Behavioural/defensive responses

18. Causes of shame - triggers
 Shame is a pan-human defensive emotion evoked by
two different types of relational events:
 1. The recognition of one’s own inferior status and
resultant aversive feelings.
 2. The recognition of the self’s failure to conform to
social norms and expectations.
 Fessler, 2007; see also Budden, 2009

19. Shame - affect
 Shame is typically a blend of other (basic) emotions
like anger, anxiety and disgust (Gilbert, 1998, 2010)

20. Shame & attributions (cognitive)
Shame
Tracy & Robins, 2008
Internal Stable Uncontrollable Global

21. Shame – behavioural responses
Compass of shame
(Nathanson, 1992)
Attack self
Avoid Withdraw
Attack other

22. One typology of shame
 External shame: thoughts and feelings about how
one is believed to exist in the minds of others
 Internal shame: self-directed evaluations,
thoughts and feelings about inadequacies and
flaws.

23. Trauma and shame (cont.)
 People feel ashamed for:
 1) what happened
 2) how they (e.g., their body) responded
 3) who they are
Boon, Steele, & Van der Hart, 2011; Dorahy & Clearwater,
2012, Herman, 2011; Talbot, 1996

24. Shame
Embarrassment
guilt
Hi self crit.
Relational trauma/victimisation
narcissism
Anger/disgust
directed
at self
Other’s appraisals
of self
Dep, low SE
Suicide
humiliation
Exposure + neg action
Exposure + pos action
Incompetence
Inferiority
Defective
Exposure but self not to blame
Violation of values
Defense against
shame
Empathy
absent
Empathy
present

25. Differentiating guilt and shame
S
h
a
m
e
G
u
i
l
t
Emotion of social sanction Emotion of internal sanction
Related to entire self Related to specific behaviour
Concerned with ideals Concerned with prohibitions
Self-oriented Other/communal-oriented
Teroni & Deonna, 2008

26. Differentiating guilt and shame
Sh
a
m
e
G
ui
l
t
Fear of intimacy
No intimacy fear
Behavioural and
characterolog. self-blame
No blame of others
Blame of others
Self-derogation
Lutwak, Panish, & Ferrari, 2003

27. Shame: Behavioural markers and
actions
Shame
Blushing
Diverting eye
Gaze/breaking eye
contact
Hunching of
Shoulder/shrinking/compression
of body
Dropping of the head/
turning away
concealment
No/reduced
self relev.
Momentary
Blank
mind/inability
to speak
Movement
from others

29. Shame, Schizophrenia and EE
(Wasserman et al., 2012)
 EE evidence by criticism/hostility or emotional
overinvolvement.
 Predicts relapse and poor prognosis in schizophrenia
(Weardon et al., 2000)
 Does shame for having a family with schizophrenia
increase criticism and hostility toward that person?
 Does guilt/self blame lead to more emotional
overinvolvement (as an overcompensatory repair
strategy?
 68 family members of patients with schizophrenia or
schizoaffective disorder
Wasserman, Weismna de Mamani & Suro, 2012

30. Tools
 SCID-I diagnosis of patient; family member given:
 Five Minute Speech Sample (Magana et al., 1986) to
assess EE
 Shame and Guilt/self blame Qs for Self-directed
Emotions for Schizophrenia Scale
 “Having a relative with schizophrenia is a great source of
shame”
 “Having a relative with schizophrenia is something for
which I feel blameworthy”
 1 (not at all) - 7 (very true)

31. Do Shame, guilt predict high EE?
 Shame and guilt predict high EE
 But shame does not predict hostility/criticism uniquely
 And Guilt/self blame does not predict emotional
overinvolvement uniquely
Shame
Guilt/Self
blame
High EE
EOI
Criticism/Host.
Exp (B) =1.55
Exp (B) = 2.09

32. Shame, social anxiety, psychosis
 Shame of having the diagnosis may heighten in
schizophrenia due to stigmatisation (social rejection)
or social threat
 This may be partly associated with high social anxiety
evident in schizophrenia (+30%)
 Therefore:
 Hieghtened anxiety after first episode of schizophrenia
as stigmatisation/social threat increased
 Heightened shame in those who feel more stigmatised
by diagnosis.
Birchwood et al., 2006

33. Shame, psychosis and social anxiety
 79 individuals assessed 6 months after first episode
psychosis (mean age 23; 61 males, 18 females). 52
schizophrenia.
 23 social anxiety vs 56 no SA
 Shame measures
 Personal Beliefs about Illness Q (Birchwood et al., 1993)
– shame subscale (appraising psychosis as shameful)
 Others as Shamer Scale (Goss et al., 1994) – perceiving
as shaming because of diagnosis

34. Shame, psychosis and social anxiety
Measures Social anxiety No social anxiety
PBIQ Shame 16.5 (3.2) 12.9 (2.5)
OAS 38.3 (14.9) 18.1 (13.4)
• Social anxiety group higher shame
• Having diagnosis is shameful
• Others will shame as a result of having diagnosis
• Unfortunately no correlations provided by shame and psychotic
symptoms (i.e., is shame associated with having psychotic
symptoms).
• They would argue this relationship mediated through beliefs
about being social threatened/ostracized, rather than direct link
between psychosis and shame

35. Shame & Psychosis: Discussion
 Shame in family members regarding a person
schizophrenia increase EE environment
 Shame heightened in psychosis, especially those with
increased social anxiety (stigmatisation/fear of social
rejection)

37. Shame & DID: Starting point
 Shame discussed increasingly in complex trauma and
DID literatures (e.g., Chu, 2011; Dorahy, 2010; Dorahy
et al., 2013; Dyer et al., 2009; Kluft, 2007
 Yet, very little work has empirically examined shame in
dissociative disorders.
 Is shame elevated in DID compared to psychiatric
comparison groups?
 Is there an association between shame and
dissociation (e.g., Talbot et al., 2004)

38. Shame & DID: Method
 N = 66 psychiatric patients
 DID: n = 35;
 M= 2; age = 44.88 (sd=10.45)
 Vs
 Non-DID (e.g., DDNOS [3], PTSD [10], complex dep/anxiety[16],
BPAD[2]): n = 31;
 M=7; age = 39.51 (sd=9.73)
 Sig for age [F(1,64) = 4.62, p<.05]
 All had child abuse and/or neglect

39. Shame & DID: Scales
 Completed:
 Multidimensional Relationship Questionnaire (MRQ; Snell et al.,
1996): Rel preoccupation, Rel. anxiety, Rel. Dep. Fear of rels.; Rel. esteem,
motivation, satisfaction.
 Personal Feelings Questionnaire-2 (PFQ-2; Harder & Lewis, 1987)
 The Compass of Shame Scale (CoSS; Elison et al., 2006)
 Avoidance, withdrawal, attack self, attack other
 The State Shame and Guilt Scale (SSGS; Marschall et al., 1994)
 Stress Reactions Checklist for Disorders of Extreme Stress
(SRC; Ford et al., 2007)
 The Childhood Trauma Questionnaire (CTQ; Bernstein & Fink, 1998)
 Dissociative Disorders Interview Schedule: BPD, DID (DDIS; Ross
et al., 1989).
 Dissociative Experiences Scale (Carlson & Putnam, 1993

40. Shame& DID Results: Difference
Variable DID Non-DID F p
Abuse-Negl 86.35 (22.9) 64.13 (23.7) 19.01 .000
DESNOS 32.51 (10.4) 22.67 (9.4) 16.12 .000
DES-tot. 55.14 (18.6) 22.03 (14.1) 63.77 .000
DES-Tax. 53.14 (27.5) 14.83 (15.0) 69.24 .000
PFQ-Shame 25.71 (6.6) 19.42 (6.7) 14.95 .000
PFQ-Guilt 15.54 (4.9) 13.41 (3.7) 3.81 .055
CoSS Avoid 32.00 (6.7) 33.7 (6.8) 1.06 .131
CoSS Attself. 48.63 (9.6) 45.9 (10.4) 1.23 .27
CoSS Withd. 49.66 (6.3) 45.7 (8.4) 4.65 .035
CoSS AttOth. 23.08 (8.4) 27.29 (8.6) 3.89 .053
Rel. Preocc. 1.68 (2.7) 1.96 (4.1) .15 .70
Rel. Anx 15.25 (6.2) 10.71 (7.4) 7.47 .008
Rel. Dep 13.71 (5.8) 8.35 (6.3) 13.03 .001
Fear of Rel 14.57 (5.2) 11.4 (5.5) .6.14 .016

41. Study 2 Results: Correlations
DES-T Shame
DES-T
Shame .61 (.000)
Guilt .55 (.000) .59 (.000)
DESNOS .67 (.000) .70 (.000)
CoSSAvoid -.24 (.06) -.17 (.18)
CoSSAttSelf .32 (.01) .66 (.000)
CoSSWithd .54 (.000) .69 (.000)
CoSSAttOther -.18 (.15) -.04 (.48)
Rel.Preocc -.02 (.89) -.16 (.63)
Rel. Anxiety .47 (.000) .52 (.000)
Rel. Depression .46 (.000) .41 (.001)
Fear of Relationships .34 (.006) .38 (.002)

42. Does dissociation or shame predict
relationship problems?
 hierarchical regression (except on Rel preoc-no
Correl)
 Predictors: Shame (step 1); DES-T (step 1);
Shame × DES-T (Step 2)

43. What predicts rel. difficulties?
 Relationship Anxiety: RsqAdj = 28.6%, F(3,61)=9.58, p<.05
 Relationship Depression: RsqAdj=20.1%, F(3,61)=6.36, p<.05
 Fear of Relationships: RsqAdj=11.8%, F(3,61)=3.85, p<.05.
Shame
DES-T
Shame by
DES-T
Rel. Anxiety
Rel. Depression
Fear of Rels.
UniqR2=8%, p <.05
UniqR2=3%, p =.07
UniqR2=7%, p <.05
UniqR2=4%, p =.07

44. Discussion
 DID higher on dissociation and shame than tight non-DID
comparison
 Also higher on relationship anxiety, depression and fear of
relationships
 Dissociation and shame related to:
 shame, withdrawal and attack-self (thus dissociation
association with more awareness of shame)
 Relationship anxiety and depression, & fear of rels.
 Both shame and dissociation uniquely predict different
aspects relationship difficulties
 Both predict rel. anxiety (dissoc-trend).
 Dissoc predicts rel depression
 Shame predicts fear of relationships (trend)

45. Shame, psychosis & dissociation:
the future
 Both schizophrenia and DID relational disorder
 Etiology:
 DID, ?Schizophrenia
 Content and nature:
 DID
 Other ‘selves’, ‘personified’ object relations (internal)
 How other people relate to person (external)
 Schizophrenia
 Auditory verbal hallucinations, ego-dystonic objects
relations (internal)
 How other people relate to person (external)
 All these areas ripe for investigation of shame,
especially comparative work

47. Therapy as shaming
 “Because of the power imbalance between patient and
therapist, and because the patient exposes her most
intimate thoughts and feelings without reciprocity, the
individual therapy relationship is to some degree
inherently shaming” (Herman, 2011, p. 271).

48. Why is shame so hard to access in
clients?
 Risks in telling shame narratives for client:
 Being perceived as inferior (thus reinforcing shame).
Feeling they may be perceived as even less than they
were before narrative.
 Evoking disgust in the other and therefore repelling
them.
 The connection, even if tentative and weak with
therapist will be broken.
 Having importance of this feeling dismissed, overlooked
and ignored

49. Pacing shame in therapy
 “In the same way that narratives of fear must be
titrated so that the client experiences mastery over fear
rather than a reinstatement of it, so too narratives of
shame should be titrated so that the client experiences
dignity rather than humiliation in the telling” (Cloitre,
Cohen, & Koenen, 2006, p. 290)

50. Roadblocks - therapeutic
relationship
 “Transformation of shame is highly dependent on
the therapeutic relationship” (Greenberg & Paivio, 1997, p. 235)
 The quality of therapeutic relationship is highly
dependent upon the client AND the therapist
 “Shame triggered in either therapist or patient can
be a source of therapeutic rupture” (Gilbert & Procter,
2006, p. 353)

51. Roadblocks: the therapists
 What is one of the biggest impediments to the
clients overcoming shame?
 The therapist!!!!

52. Shame in psychotherapy
 “Despite its destructive toll, shame seldom is
addressed in psychotherapy. Patients almost never
disclose shame as a presenting complaint, and
psychotherapists often do not address shame due
to difficulties sifting through countertransference
issues unique to shame (Hahn, 2000) and their
own painful encounters with shame in childhood
and psychotherapy supervision (Hahn, 2001)”
 Hahn, 2009, p. 303