Overcoming Shame and Self-Loathing Manual - 046675

Overcoming Trauma-Related Shame and Self-Loathing

Janina Fisher, Ph.D.

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Janina Fisher, Ph.d. is a licensed clinical psychologist and instructor at the trauma Center, founded by Bessel van der Kolk, Md. a faculty member of the sensorimotor Psychotherapy institute, an eMdr international association consultant, past president of the New england society for the treatment of trauma and dissociation, and former instructor, Harvard Medical school, dr. Fisher lectures nationally and internationally on the integration of the neurobiological research and new trauma treatment paradigms into traditional psychotherapies.

Shame and Self-Loathing in the Treatment of Trauma

PESI WebcastMonday, December 9, 2013

Copyright 2013: Janina Fisher, Ph.D. Do Not Copy without Permission 1

Transforming Shame and Self-Loathingin the Treatment of TTrauma A PESI WebcastDecember 9, 2013

Janina Fisher, Ph.D.f h

Shame and self-loathing create vicious circles for trauma survivors, inhibiting healthy therapeutic change

Shame acts as a barrier to Shame acts as a barrier to resolution in trauma treatmentresolution in trauma treatment

The persistence of shame responses, even after years of treatment, poses a barrier to final resolution of trauma. Full participation in life, pleasure and

t it h lth lf t t t dspontaneity, healthy self-esteem are counteracted by recurrent shame states and intrusive thoughts

Shame is not only triggered by criticism, normal mistakes, and less-than-perfect performance but also by success, being seen, self-assertion, self-care, asking for needs, and feeling proud or happy

Fisher, 2011




[When] a relationship of dominance and subordination has been established, feelings of humiliation degradation and shame are

The Role of Shame in the Context of Trauma

of humiliation, degradation and shame are central to the victims experience. Shame, like anxiety, functions as a signal of danger, in this case interpersonal or social danger.

Judith Herman, 2006

Like anxiety, [shame] is an intense overwhelming affect associated with autonomic nervous system activation,nervous system activation, inability to think clearly, and desire to hide or flee. Like anxiety, it can be contagious.

Herman, 2006

Why does shame Why does shame stick like gluestick like gluefor decades after the trauma?for decades after the trauma?

Shame is a survival response, as crucial for safety as the animal defenses of fight, flight, and freeze

Not only is shame a powerful body response, it is accompanied by meaning making that exacerbates the bodyaccompanied by meaning-making that exacerbates the body responses and creates a vicious circle of shameWhereas fear focuses on the source of threat, shame feels personal: its about meShame is often reinforced by other trauma-related schemas, such as Its not safe to succeedto be self-assertiveto have needsto be happy Fisher, 2010




Humans depend upon the same Humans depend upon the same defensive responses as animalsdefensive responses as animals

We either cry for help

Or we try to fight

We freeze and try to be invisible

Or we submit in humiliation

Or flee

In conflict situations, there are just two basic choices: to escalate or de-escalate. . . . The inhibitory functions

Shame as a Survival Resource

of shame suggest that shame functions as a defensive strategy which can be triggered in the presence of interpersonal threat. . . .

Gilbert & Andrews, 1998, p. 101

Shame signals (e.g., head down, gaze avoidance, and hiding) are generally registered as submissive and [appeasing], designed to de-escalate and/or escape from conflicts. Thus, insofar as shame is related to submissiveness and appeasement behaviorto submissiveness and appeasement behavior, it is a damage limitation strategy, adopted when continuing in a shameless, nonsubmissive way might provoke very serious attacks or rejections.

Gilbert and Andrews, 1998, p. 102




After trauma is over, we After trauma is over, we rememberrememberit with our bodiesit with our bodiesBrain scan research demonstrates that traumatic memories are encoded implicitly as bodily and emotional states more than in narrative form

But when trauma is remembered withoutBut, when trauma is remembered without words, it is not experienced as memory. Thesenon-verbal physical and emotional memory statesdo not carry with them the internal sensation that something is being recalled. . . . We act, feel, and imagine without recognition of the influence of past experience on our present reality. (Siegel, 1999)

Fisher, 2009

When the images and sensations of experience remain in implicit-onlyform. . ., they remain in unassembled neural disarray, not tagged as representations derived from the past . . . Such implicit-only memories continue the shape the subjective feeling we have of our here-and-now realities, the sense of who we are moment to moment, but this influence is not accessible to our awareness.

Siegel, 2010, p. 154

Fear and Shame in a Threatening WorldFear and Shame in a Threatening World

Hyperarousal-Related Symptoms:Anxiety, panic, terror, dread, racing thoughtsFear, anger, and longing are predominant emotional statesHypervigilance, mistrust, resistance to treatment Response to triggers is action: fight/flight, self-destructive/addictive behavior

Sympathetic

Window of Tolerance* Optimal Arousal Zone:

Hypoarousal-Related Symptoms: Depression, sadness, numbing Preoccupation with shame, despair and self-loathing Mistrust disguised by automatic compliance Response to triggers is inaction: giving in, passive resistance, inability to say No

Parasympathetic

Ogden and Minton (2000); Fisher, 2009 *Siegel (1999)

The frontal lobes shut down




Neurobiological Purpose of Shame Neurobiological Purpose of Shame [Schore, 2003][Schore, 2003]

By toddlerhood, before the development of greater top-down control, children need for their own safety to respond quickly to inhibitory cues. Allan Schore hypothesizes that shame develops at this developmental stage as a neurobiological regulator that serves thestage as a neurobiological regulator that serves the purpose of helping children inhibit behavior.

In a state of high energy and action-orientation, children are sympathetically activated and more impulsive. To inhibit such behavior, the parasympathetic system must act as a brake. This simple autonomic device can be protective unless parents fail to soothe shame states

Fisher, 2013

The Purpose of Shame, cont. The Purpose of Shame, cont. [Schore, 2003][Schore, 2003]

When shame rapidly down-regulates excitement and impulsivity, the child freezes momentarily, then inhibits the forbidden action. Sympathetic highs are interrupted by rapid parasympathetic deceleration

Wh th h i i d b th tWhen these shame experiences are repaired by the parent with soothing and clarification, resilience increases (Tronick)

But, in unsafe environments, shame must be over-usedto down-regulate fight/flight reactions and other behavior unacceptable or unsafe in the environment.Under conditions of neglect and/or abuse, shame states are not repaired by the caregiver, decreasing resilience Fisher, 2011

[Shame] perhaps more than any other emotion is intimately tied to the physiological expression of the stress response. . . . This underscores . . .the function of shame as an arousal blocker. Shame reduces self-exposure or self-exploration.

Schore, 2003, p. 154




Shame as a Source of SafetyShame as a Source of SafetyIn traumatic environments, because of its role in downregulating activation, shame helps to drive the animal defense of submission: shame responses cause us to avert our gaze, bow our heads, and collapse the spine. Among animals, this is an appeasement signalg , pp g

In an environment in which self-assertion is unsafe for the child, shame enables the child to become precociously compliant and preoccupied with avoiding being badThis shame-related avoidance of potentially dangerous behavior and procedurally learned submissiveness is adaptive in traumatogenic environments Fisher, 2013

Persistent Shame Responses Persistent Shame Responses Reflect Procedural LearningReflect Procedural Learning

Procedural memory is the implicit memory system for functional learning: skills, habits, automatic behavior, conditioned responses. Driving a car playing an instrument swimming or playingDriving a car, playing an instrument, swimming or playing tennis, riding a bike, shaking hands and making eye contact, even dissociating or switching, are all examples of procedural learning. Procedural learning allows us to respond instinctively, automatically, and non-consciously, increasing our efficiency at the cost of a loss in reflective, purposeful action Fisher, 2006

Sensorimotor Psychotherapy Institute

[Procedural] memory shapes how we experience the present and how we

Procedural learning facilitates automatic responding

anticipate the future, readying us in the present moment for what comes next based on what we have experienced in the past.

Siegel, 2006




When I was young, my parts built their own little world that explained what was happening to them.And what was their explanation?They thought, if I wasn't so bad and ugly and if I didn't cause other people to be angry, these things

Annie on the topic of shame:

p p g y, gwouldn't be happening to me." What were the advantages of that explanation?

"It limited how much people could get to them. If something is wrong with you, you can work on you. You don't have to try to figure out why the bad things are happening because you already know.

Sensorimotor PsychotherapySensorimotor Psychotherapy is a body-oriented talking therapy developed in the 1980s by Pat Ogden, Ph.D. and enriched by contributions from the work of Alan Schore, Bessel van der Kolk, Daniel Siegel, and Steven Porges. Sensorimotor work combines traditional talking gtherapy techniques with body-centered interventionsthat directly address the neurobiological effects and procedural learning of trauma. By using just enough of the narrative to evoke the unresolved somatic experience, we attend first to how the body has encoded traumatic experiences and secondly to cognitive and emotional meaning-making Ogden, 2002; Fisher, 2006


The most direct way to effect change is by The most direct way to effect change is by working with the procedural learning working with the procedural learning

system. . .system. . . [Grigsby & Stevens, 2000][Grigsby & Stevens, 2000]The first [type of therapeutic challenge] is to observe, rather than interpret, what takes place, and repeatedly call attention to it.Empathy is not helpful with shame: it reinforces identification with the shame, rather than challenging it. The second therapeutic tactic is to engage in activities that directly disrupt what has been procedurally learned.But the disruption cannot be shaming to the patient:that requires that our disrupting must be done more indirectly than directly.




PsychoeducationPsychoeducationPsychoeducation is a good disruptor of shame: Psychoeducation about the ability of shame and self-blame to inhibit behavior that our parents will punish, to get us to be seen and not heardPsychoeducation about the role of shame in enforcing submission for the sake of safety. Submission must be understood as an active defense at those times when fight and flight would be dangerous or impossible

Psychoeducation about shame and cognitive schemas: The belief that you are worthless is a story you told yourselfit kept you alive Fisher, 2009

Challenges to Shame and Challenges to Shame and SelfSelf--hatredhatredMindfulness: help the client to notice the shame rather than be it. What happens in the body when those thoughts of worthlessness come up? Notice what its like to observe the shame just as body sensation . . .Dis-identification: challenging the identification with the shame as who I am. Thoughts are just theorieslets be curious about this theory that youre stupid. How would that theory have helped you survive?Reframing the shame: attributing meaning and purpose to the shame as a survival resource (Ogden et al 2006). The shame was the hero of your story. . . Fisher, 2011

Mindfulness SkillsMindfulness Skills Notice . . . Be curious, not judgmental. . . Lets just notice that reaction youre having

inside as we talk about standing up to your boy friendfriend

Notice the sequence: you were home watching TV with your husband, feeling relaxed, then suddenly you started to feel anxious, and then you felt ashamed . . .

What might have been the trigger? Lets go back to that day and retrace your steps. . .

Fisher, 2004




Differentiating Thoughts, Differentiating Thoughts, Feelings, and Body ExperienceFeelings, and Body Experience

In traditional talking therapies, we tend to treat thoughts, feelings, and body sensations as if they were one and the same. But when clients say, I feel ashamed,

Their words could convey a cognition: I believeTheir words could convey a cognition: I believe that I am defectiveThey could communicate an emotion: Im feeling humiliated right nowThey could reflect bodily sensation: I feel a flushinga sick feeling in my stomachan impulse to turn away and hide Fisher, 2013

Increasing mindful concentration: Increasing mindful concentration: offer a menu of possibilitiesoffer a menu of possibilitiesWhen the shame comes up, what happens? Do you feel it in your stomach? Your face? Or do you want to hide?

As you feel that anger, is it more like energy? Or y g gymuscle tension? Or does it want to do something?When you talk about feeling nothing, what does nothing feel like? Is it more like calm? Or numbing?When you say those words, It was my faultthere must be something wrong with me, do you feel better or worse? Ogden 2004


Putting words to experiences of Putting words to experiences of shame facilitates selfshame facilitates self--blameblame

Human beings are meaning-making creatures. Early in life, before we have words, brain and body make meaning of our experience. With language, we begin to attach wordsEchoing what they heard from caregivers, our clients have

attached words of blame: You stupid idiothow could you be so dumb? Youre disgusting Loser!The words of blame serve to re-evoke the shame,enforcing compliance needed to preserve safety/attachmentBut children believe the words of blame as truth about themselves. Although that belief is protective, it fuels automatic self-blame and thus more shame Fisher, 2013




ProcedurallyProcedurally--learned Selflearned Self--HatredHatredSelf-blame serves the purpose of putting the brakes on behavior that will be punished by others. In self-blame, we yell at ourselves, inducing shame. We warn ourselves never to do that again; we silence ourselves; we withdraw. The key here is that shame is active and protective Internalizing the punitive role ensures safety and a greater sense of controlat the cost of punitive introspection. But self-hatred is a small price to pay for greater safety. Once self-hatred is procedurally-learned and encoded in the body and mind, it feels true. It continues to exert an influence on self-esteem and healthy self-assertion long after its job is over Fisher, 2012

Shame and BlameShame and BlameAnnie F.: Blame' and 'shame' are best friends. When my parts blame themselves for what was done to them, they are saying that they did 'something' wrong. And that 'something' had consequences.... such as that my body was bruised, or eyes swollen from crying, or hair

d d l d d f b ll fmessed up and tangled, and even a fat belly from a rape. That 'I' was to blame for looking and feeling so badly was just the beginning of my shame.Annie F.s epiphany describes blame and self-loathing as essential ingredients of shame as a survival response. The blaming thoughts instigate shame responses followed by automatic submission responses Fisher, 2010

Cognition and the bodyCognition and the bodyThe body responds not only to physical and emotional stimuli (sights, sounds, touch, facial expressions) but also to words and the tone in which they are spokenGood job! evokes a different bodily response than You did a terrible job! What are you doing here? has adid a terrible job! What are you doing here? has a different impact than Welcome---its good to see youIn order to treat the body aspect of the shame response, we need to help clients notice the vicious circle between the words they use and the body responses evokedAnd we have to help them experiment with new words that have a different impact on body experience Fisher, 2011




Dropping the ContentDropping the Content An important sensorimotor skill for decreasing shame is An important sensorimotor skill for decreasing shame is

learning to learning to drop the content:drop the content: to focus to focus awayaway from from shameshame--based thoughts, interpretations and feelings and based thoughts, interpretations and feelings and instead to focus attention instead to focus attention towardtoward the body sensations OR the body sensations OR just external stimulijust external stimuli

For mindful clients, dropping the content and shifting For mindful clients, dropping the content and shifting focus to internal body awareness can be regulating. For focus to internal body awareness can be regulating. For less mindful or more unstable clients, letting go of the less mindful or more unstable clients, letting go of the contentcontent is only possible when they focus on something is only possible when they focus on something concrete, such as their feet concrete, such as their feet

Dropping the content to focus on the body challenges Dropping the content to focus on the body challenges negative cognitions: negative cognitions: the words lose their powerthe words lose their power Fisher, 2008Fisher, 2008


Combating Shame Through the Combating Shame Through the BodyBodyIf the shame is reinforced or exacerbated by body experiences of collapse, loss of energy, feelings of revulsion, curling up or turning away, then shame can be mitigated by changing body postureg y g g y p

Lengthening the spine and grounding through the feet both challenge shame. If the clients head is bowed or averted, bringing the head up or asking the client to begin to slowly turn the head and lift the chin can begin to increase feelings of confidence and fearlessness. If these movements are triggering, they can be executed piece by piece over time Fisher, 2009


Fisher, 2000




Clinical Advantages of Working Clinical Advantages of Working with Shame as a Child Partwith Shame as a Child PartWhen we re-frame shame or self-hatred or schemas as just a part of the self, we interrupt procedurally-learned automatic shame responses and increase curiosityThe language of parts also increases mindfulness: IThe language of parts also increases mindfulness: Iis the first word in a narrative about the shame, while the language of parts encourages noticing internal experienceIf there is a part that holds shame and a part that holds blame, by definition there is a part that sees those other parts (an observing ego). There may even be parts that hold a more updated view of who the client really is

Fisher, 2011

Working with Ashamed PartsWorking with Ashamed PartsShame: The ashamed parts shame is best addressed as a somatic resource. Explore its role in how the client survived: how did it serve to regulate fear? Or anger? It couldnt stop the perpetrators, but how did it protect the child? Did it support the child being seen and not heard?child? Did it support the child being seen and not heard ?Shame and self-loathing-related cognitions: when re-framed as survival beliefs held by parts, shame-based cognitions lose their power. How did it help that the ashamed part believed that she deserved the abuse?What would have happened if she had believed he was wrong? What would have happened then?

Fisher, 2013

Working with Working with Beliefs as Child PartsBeliefs as Child PartsAsk the client to assume that the belief is held by a part of the self: What part believes she is worthless and undeserving? What part believes it isnt safe to trust?When that part feels shame, what happens in your body?Increase the clients mindful curiosity: How would itIncrease the client s mindful curiosity: How would it have been adaptive for that part to be convinced that she is worthless and undeserving? How did that affect your/her behavior in your family environment?Most often, the belief served a defensive function. It was a survival resource: Yes, the ashamed part is the hero of your story, isnt she? She kept you safe. . . What happens inside as she takes that in? Fisher, 2009




Establishing relationships Establishing relationships between adult self and partsbetween adult self and partsTrauma alienates us from ourselves and our parts from each other. To combat shame requires welcomingashamed parts and evoking mindful curiosity about their feelings, thoughts, and impulses. Bringing them alive naturally enhances empathy: How old might this part be? Very young? Middle-sized? A teenager? Is this part more emotional or logical?As curiosity challenges the automatic animosity toward parts and they come to be better understood, the therapist can ask an Internal Family Systems (Schwartz, 2001) question: And how do you feel toward that part now? Fisher, 2012

Establishing relationships with Establishing relationships with parts, cont.parts, cont.How do you feel toward this part now? is a question that naturally invites compassion and is also a litmus test for mindfulness: does the client have enough mindful distance to feel curiosity or compassion for this part? If the client responds with hostility, we can assume that she is blended (Schwartz, 2001) with parts that judge the ashamed part as weak or shameful. If the client responds, I feel badly for her or I want to help him, we know that a relationship is beginning to form. The key to establishing compassion for ashamed parts is the appreciation of their role in survival Fisher, 2012

. . . the brain changes physically in response to [new] experience and

Neuroplasticity and the Role of Repetition

response to [new] experience, and new mental skills can be acquired with intentional effort and focused awareness and concentration.

Siegel, 2010, p. 84




The first principle is that neuroplasticity is induced by changes in the amount [and kind] of sensory stimulation reaching the brain (Schartz & Begley, 2002, p. 16). The second principle is that neuroplasticity has to be directed: calculated, repetitive patterns of stimulation

Principles of Neuroplastic Change

, p pare necessary to obtain specific brain change. That requires us to be active, unafraid to be repetitive to directthe client in changing his/her habitual actions and reactionsThird, neuroplasticity requires focused attention. Attention stimulates neuronal firing in the areas we wish to restructure and also helps the brain to retain the new learning. Fisher, 2013

Principles of Neuroplasticity, cont.Principles of Neuroplasticity, cont.The last and perhaps most important principle: neuroplastic change requires that we help clients consistently inhibit the old responses and then engage in intensive repetition of new, more

d iadaptive responses.We cannot develop new patterns if we habitually engage in procedurally-learned patterns or fail to practice new habits. Whether we directly teach clients to inhibit self-blame or indirectly disrupt their habitual patterns, it is a prerequisite for change

Fisher, 2013

"If I accept you as you are, I will make you worse. If I treat you as though you are what you y g y yare capable of becoming, I will help you become that."

Johann Wolfgang von Goethe




Brain to Brain: interactive regulationAs we consistently re-frame the shame as a child part or a trauma-related belief or life-saving procedural learning, it slowly becomes easier for clients to inhibit their automatic self-blame or thoughts of self-loathingAs our shining eyes communicate that the clients g yashamed or judgmental parts are welcome and valued here, clients begin to develop greater capacity to turn shining eyes on their younger selves. As our faces soften and our voices become warmer, the client begins to soften as well, relaxing the body and creating a pervasive sense of warmth. OUR acceptance becomes THEIR acceptance. Fisher, 2012

Annie: Until today it didn't seem possible that the ashamed parts would ever feel any respite from the searing embarrassment caused by any mention or reference to the kinds of crimes committed against them as children. In the minds of the parts, they were complicit in the acts against them. The warriors thought of the ashamed parts as weak and disgusting, too, not as vital to my survival. And I wasn't helping those ashamed child parts because I was blended with them.

Shame is a powerful weapon that the abusers counted on. I can see that now. How different it feels in my body to acknowledge submission as a survival tactic that was smart and courageous of my young parts to access! Their submission and subsequent shame may be the reason wesubsequent shame may be the reason we survived. So, now there is more hope for healing. Every time I '"hang in there" with my back straight and my feet firmly planted on the ground, the parts that feel so much shame will see that they are really heroes.




For further information:

Janina Fisher, Ph.D. 5665 College Avenue, Suite 220COakland, CA 94611 USA

[email protected]

Sensorimotor Psychotherapy Institutewww.sensorimotor.org

Sensorimotor Psychotherapy Sensorimotor Psychotherapy Institute Training for the Institute Training for the Treatment of TraumaTreatment of TraumaTreatment of TraumaTreatment of Trauma

www.sensorimotor.orgwww.sensorimotor.org

For information, email:For information, email:[email protected]@sensorimotor.org

Working with the Neurobiological Working with the Neurobiological Legacy of TraumaLegacy of Trauma

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A ten-month remote-learning webinar program for mental health professionals interested in developing

greater comfort and expertise in working with complex g p g ptrauma and dissociation while staying abreast of recent

trauma-related research and treatment advances.

All programs are recorded and available for later viewing online.

Janina Fisher, PhD. is a clinical psychologist specializing in treatment of complex PTSD and dissociation. She is also an instructor & supervisor at the Trauma Center, past President of the New England Society for the

Treatment of Trauma & Dissociation, a trainer for the Sensorimotor Psychotherapy Institute, an EMDR Approved Consultant, and an international presenter on the neurosience research and treatment of trauma-related disorders.

For more information or to register, email Dr. Fisher or go to www.janinafisher.com

Overcoming Trauma-Related Shame and Self-Loathing with Janina Fisher, Ph.D. Program Objectives Please use the objectives below to answer the online objective questions. At the completion of this seminar, I have been able to achieve these seminar objectives: Help clients appreciate the role of shame and self-loathing as symptoms of

trauma Identify the neurobiological effects of shame Discriminate the physiological and cognitive contributors to shame Describe cognitive-behavioral, ego state, and psychoeducational

interventions to address shame **Please mark any additional objective questions online not applicable.

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Overcoming Shame and Self-Loathing Manual - 046675