Shame and guilt: A synthesis

Treatment preparatory to psychoanalysis: a reconsideration after twenty-five years

The author's initial article on treatment preparatory to psychoanalysis (1983) challenged the long-held belief that a therapy with the same analyst would contaminate a subsequent analytic transference. The current article reconsiders the original process of transition from therapy to analysis and describes methods that can further its effectiveness. Although specific noninterpretive interventions to enhance preparation for analysis are rarely written about, they are discussed among colleagues and in supervision. Levy (1987) has described a bias against the description of strategic or tactical choices in analysis. It is increasingly clear that some patients' fear of exposing shameful defectiveness underlies their resistance to entering analysis, as does the originally described fear of an uncontrolled regression. It is useful to delay interpretation until shame sensitivity can be assessed and modulated. In the past there was pressure to keep the preparatory therapy brief so that the analyst would not become too well known to the patient. Less concern about strict anonymity allows more time for the patient's resistances to abate before the recommendation is made. Methods are described and clinical illustrations show how a deepening process can be fostered, how indications of readiness for the transition can be assessed, and when and how the recommendation can be made.

The necessity of combined therapy in the treatment of shame: a case report

Abstract In some situations, combined psychotherapy may not be merely a choice, but a necessity for successful treatment. I present a case report of a hospitalized Vietnam veteran who had sexually abused one of his daughters. In individual therapy, the patient learned to speak about himself, his significant guilt, and his shame, in a trusting environment. After a year of outpatient individual work, I felt that the addition of group psychotherapy would help this withdrawn man to connect to a social milieu. Although anxious about self-disclosure and confidentiality, he joined a heterogeneous veterans' group, and came to reveal his secrets there. While he continued to use the individual sessions to broach painful issues, the group served to uncover material that had not emerged otherwise. The acceptance he experienced in the group expanded and cemented gains made in the dyad, which in turn made the ongoing group experience tolerable. His self-exposure and efforts at bonding and reparation catalyzed therapeutic movement for other members as well. The two modalities served to reinforce and make more powerful the effects of each. Therapeutic progress depended on the combined treatment-both were necessary, neither was sufficient.

Narcissism as motive

This essay proposes replacing the traditional concept of narcissism as derived from the theory of drives with a concept of narcissism that is concerned with motives and their correlative meanings-specifically, motives connected to self-organization, self-preservation, self-cohesion, self-valuation, and self-esteem. The reasons for and the metapsychological underpinnings of a motivationally based theory are discussed. This revised motivational view proposes that narcissistic dynamics can be preserved and articulated in exclusively motivational terms. Developmental aspects are explored, including formation and functioning of the ego ideal and self-esteem regulation. Implications for psychoanalytic technique are suggested in discussions of case material.

Shame and psychopathology

The origins of the word "shame" recall the concept of the infraction of integrity both as scandal and as individualization. The human experience of shame stretches along a continuum from modesty to disabling interpersonal terror. Unlike other basic affects, its emergence is a fundamental moment in the process of self-awareness and self-object differentiation. Neglected by psychiatry because it was regarded as a moral concept, today it is possible to hypothesize that it has a biologic basis that one can attempt to describe in terms of corticothalamic pathways. In this respect, like other affects, it could be considered as a cognitive shortcut to activate specific and evolutionally useful behavioral patterns, such as concealment or a request for affiliation. It is fairly ubiquitous in psychopathology, but is clinically much more structured in its abnormal expressions in anxiety disorders, particularly social phobia, obsessive-compulsive disorder, eating disorders, body dysmorphic disorder, and even in bipolar mood disorder. In schizophrenia it has been described as being one stage in the construction of delusion. Its presence is connected to interpersonal relationship (altruism) though it seems absent in autism. The assessment of shame experiences in psychiatric patients could be useful for both pharmacological and psychotherapeutic strategies, and could provide a categorization of a new psychopathology based on abnormal affects.