Understanding What is Hidden

Treatment of Victims of Sexual Abuse

0193-953X/89 $0.00

+ .20

Understanding What Is Hidden Shame in Sexual Abuse

Donald L. Nathanson, MD*

Surrounding the actions, the behaviors that are discussed as sexual abuse are a wide range of emotions that infuse and power these actions and leave in their wake still more emotions that power still more behaviors. Our psychotherapeutic treatment of the victims of such abuse can be effective only to the extent that we understand the emotions involved. Whenever people are made powerless or helpless they experience shame; ridicule, contempt, disdain, and cruelty can activate shame; any invasion of privacy must trigger shame. Sexual abuse involves all of these common releasers of shame; yet despite the importance of embarrassment, humiliation, or any of the shame of family emotions in those who come to us for treatment of such distress, the clinician rarely organizes treatment in terms of this central issue. In this brief article, I will summarize our current thinking about shame and suggest how an increased understanding of shame may augment our treatment of the victims of sexual abuse.

UNDERSTANDING SHAME: AFFECT AND EMOTION In our culture, sexuality is linked with shame to such an extent that many observers so misunderstand this innate affect that they believe all shame to be somehow sexual. Wurmser16•17 offers a different and far more useful approach, defining shame as a response to exposure, an emotional response impelling us to hide. What is exposed in the moment of shame is something deeply personal, some particularly intimate, sensitive and vulnerable aspect of the self. Unlike guilt, the complex emotion released when we have violated some rule or done harm to another person, shame monitors our sense of self. There may be no emotion that wounds as deeply as shame, no pain as searing. Kaufman6 points out that the adult trigger to shame is a sundering of

*Senior Attending Psychiatrist, The Institute of Pennsylvania Hospital; Clinical Associate Professor of Psychiatry, Hahnemann University, Philadelphia, Pennsylvania

Psychiatric Clinics of North America-Vol. 12, No. 2, June 1989

381

382

DONALD NATHANSON

the "interpersonal bridge," our sense of connectedness to the human world around us. Betrayal, treachery, and abandonment can activate shame; in the moment of shame, we feel alone, rejected, shorn from all human contact. Fenichel5 says "'I feel ashamed' means 'I do not want to be seen.'" If we are to be seen at all during the experience of shame it is with the hope that we will be seen as different from how we have just appeared to the one who has exposed us. Lewis 7 •8 suggests that the blush functions to tell the shaming other that we have recognized the unworthiness of our self image and now wish to be accepted back into society. Every action we perform is evaluated by us to see whether it brings us closer to our idealized self image (our personal best) or closer to our personal worst self. Movement closer to our personal best triggers pride, while recognition of failure or defeat triggers shame. Our behavior defines us and must always be ranked on a shame/pride axis. From early infancy competence linked with excitement or contentment brings pride, whereas incompetence and the failure to control one's actions bring shame. 3 .10.11 Elsewhere 10 I have described in detail a timetable for shame, suggesting (in the language of Tomkins 15) that a physiologic mechanism initially serving to reduce the innate affects of excitement or contentment (in situations where the organism is unable to do so voluntarily) is triggered by an error correcting feedback mechanism. 2 I think it likely that physiologic innate shame affect ("protoshame") involves a neurohumoral vasodilator substance mediated upward, both developmentally and phylogenetically, from a subcortical affect center to influence higher structures. Protoshame, this hypothesized physiologic innate affect, causes an acute loss of tonus in the head and neck and a rapid aversion of eyes and face from whatever pattern mismatch has triggered it. Within moments, both cortex and neocortex are administered a cognitive shock, accounting for the brief period of cognitive incapacity always accompanying the acute experience of shame; the blush may be an extracranial expression of this vasodilator substance. During the first 2 years of life this physiologic mechanism becomes coassembled with a host of other life experiences to take on the wide range of cognitions associated with the group of adult emotions variously called embarrassment, shame, mortification, or humiliation, and known as the response to ridicule, contempt, and being seen as defective. It is important for the clinician to recognize that shame involves both a physiologic and a cognitive experience. The moment of cognitive incapacity, of head hung low and eyes averted, of blush, and isolation - these represent the biology of innate affect mechanisms. In the brief seconds that follow, the neocortex recovers sufficiently to scan memory for our associations to previous experiences of this affect, producing what for each of us is regarded as the mature personal emotion we call shame. Everything that has ever embarrassed us will float into consciousness, producing what Wurmser 16 called the layering of shame emotion: "What one is ashamed for or about clusters around several issues: (1) I am weak, I am failing in competition; (2) I am dirty,

UNDERSTANDING WHAT

Is

HIDDEN

383

messy, the content of my self is looked at with disdain and disgust; (3) I am defective, I have shortcomings in my physical and mental makeup; (4) I have lost control over my body functions and my feelings; (5) I am sexually excited about suffering, degradation, and distress; (6) watching and self exposing are dangerous activities and may be punished." No matter what has triggered shame affect, shameful thoughts analogous to these will occupy the attention of the person involved. Even if shame affect is produced by the ingestion of chemicals like alphamethylparatyrosine, 12 the mind (having no experiential analogue for "chemical" shame) will scroll through associative memory to find an "appropriate" cause. CLINICAL MANIFESTATIONS OF SHAME So noxious is the experience of shame that often we defend against it by disavowing whatever percept might act as a trigger. 4 In a recent session, a 35-year-old woman complained that she was "having a fat attack." That morning she had gone through her entire wardrobe, unable to find any garment in which she looked acceptable to herself, and decided that she needed to go on a diet despite the refusal of the scale to confirm any recent weight gain. Eventually we realized that she had awakened from a dream, analysis of which led us forward in time to her uncomfortable anticipation of a review by a contemptuous superior at work, and backward through her life to reveal a myriad of experiences with her shaming father. This women is quite comfortable with whatever beauty and intelligence are hers by birthright, but by focusing on an aspect of shame ("I am defective, I have shortcomings in my physical and mental makeup.") less painful than her anticipation of humiliation at work, she remained within the shame experience at a far safer layer. Often patients who have been humiliated are unable to reveal to themselves or to us the actual cause of their discomfort until we have made them feel safe with the very idea of shame. Notice the reticence with which people discuss what embarrasses them. To the extent that shame reflects weakness, frailty, vulnerability, defect, or deficit, we are ashamed of ourselves for being ashamed. Too often we therapists remain silent before the silence of our patients; some patients all the time and all patients some of the time are mute for fear of humiliation and must be reassured that we understand uncovering therapy as what Anthony1 has called "an arena of shame." Yet does not this understanding of shame help us approach those whose sexual nature has been exploited by others or who have been reduced to the status of things by outright abuse? SHAME IN SEXUAL ABUSE Here is a vignette from a supervision session with a competent resident: After 2 years of once-weekly outpatient treatment, a 25-year-

384

DONALD NATHANSON

old woman described for the first time an incident that had occurred a few days before she decided to seek psychotherapy. She had arrived at her boyfriend's apartment to be greeted by his somewhat inebriated weight-lifter brother, who raped her and departed after threatening her life should she make any attempt to seek redress for his actions. The boyfriend returned home to find her in a state of acute distress. Through her tears she explained what had happened, including the indignity of the rape and her terror of his brother. As part of his effort to comfort her, the boyfriend forced her to have intercourse with him. Why, asked the resident, did she wait 2 years to bring this up in therapy? Why did the boyfriend compound her distress at a time when she clearly needed nonsexual succor? Why this rape, why do men rape at all, and why do we see sexuality used so often in the expression of power and dominance? We decided that she had waited until she felt safe within the therapeutic relationship, secure in her understanding that he would not humiliate her further when he learned about her searing humiliation. I think she would have discussed the rape, and a host of other humiliations, much earlier in treatment had he focused on the relationship of shame to all exposure and on the inherently shameful quality of psychotherapeutic disclosure. I mentioned to the resident that Freud became so certain of the importance of psychosexual development that he defined as resistance (or even worse, "The Resistance") the natural reticence of someone in our culture to discuss sexual fantasies and sexual experiences. To resist psychoanalytic inquiry itself became a source of shame; Freud failed to understand the normal range of operation of shame affect, which includes such functions as its stewardship of modesty and privacy. 13 Whenever we encounge someone to divulge what has been hidden, we must understand the full range of shame experience that may accompany disclosure. But the boyfriend's decidedly unempathic seduction - can our understanding of shame explain that perversion of trust? It is easy to speculate that he too felt humiliated, for his brother had stepped in and taken by force the sexual intimacy that had been his alone, intruding into his privacy. The emotion of shame can broadcast from one person to another with such power that, resonating with her humiliation, he may have felt constrained to overcome his own sense of incompetence and deficit (his own version of the layers of shame described here) by demonstrating his sexual prowess, as much to himself as to her. There are other levels to study here. Shame and pride will always be intimately involved where matters of control are predominant; intrinsic to sexual pleasure are sequences of control and dyscontrol. For a boy, one of the tasks of puberty is mastery of his penis, a part of his body suddenly woefully out of his control as it springs unbidden into erection or humiliates him with an unexpected ejaculation. Healthy sexuality for both men and women involves openness, trust, intimacy, and safety; yet for men there is an added factor stemming from adolescent issues of control and mastery. On the few occasions that I have been privileged to study/treat an admitted rapist, I have been impressed by the degree to which his personality structure has been governed by shame conflict. Wherever we cannot raise our self-

UNDERSTANDING WHAT

Is

HmDEN

385

esteem by actions that bring us closer to our idealized self-image, we can at least lower the self-esteem of another person in our interpersonal field so that we can be "better" than someone - a false pride that hides temporarily our chronic personal shame. Conventional sexual behavior involves (in addition to the pleasure specific to sexuality) a dance in which people choose partners who will allow them to experience pride by demonstrating competence or efficacy; the continuum between the dance of seduction and the danse macabre of rape indicating the degree to which at least one of the partners is motivated by disavowed shame. All sexual behavior is ringed 'round by shame; there is no way to think about, study, understand, or treat sexuality without understanding shame. Similarly, there is no way to think about, study, understand, or treat sexual abuse without understanding shame. As far as I can determine, shame is the key issue in sexual abuse; when clinicians focus on matters other than shame, they have either fallen into the trap of accepting the defenses produced by or accompanying shame or they have succumbed to their own disavowal of shame and the pervasiveness of shame-based psychopathology. Nowhere in the literature on the treatment of sexual abuse have I found a competent reference to the psychology of shame or the cardinal importance of designing a therapeutic strategy around an understanding of the relationships between shame and sexuality, between shame and sexual abuse, or between shame and therapeutic exposure. A list of those whose comments are echoed by the preceding passage would be a chronologic list of all who have written on shame. So painful is the experience of shame that in our culture we are ashamed of shame itself. Shame, the affect that impels us to the action of hiding, itself becomes something to hide. Even the growing legions of therapists who minister to those who have been sexually abused seemingly ignore or misunderstand the stigmata of shame. Anger, weeping, shyness, bashfulness, stammering in confusion, the blocking of thought in highly charged situations, the averted eye or downcast glance, a hand covering forehead or eyes, unexpected or unexplained reddening of the skin about the head or neck, unexplained lapses in memory, missed appointments "just as we seemed to be getting to something," seemingly "paranoid" allegations made by the patient concerning the likelihood that the therapist might discuss the material of therapy with others ("Do you talk about your cases with other therapists?" "How often do you write articles about your patients?"), defense by vagueness or the rapid-fire presentation of fascinating material calculated to draw the interest of the therapist but that maintains therapy at a superficial level-all these and many, many more phenomena of the consulting room are the disguised presentations of shame in its role as the guardian of the border between exposure and privacy. SEXUAL EXPLOITATION OF CHILDREN I discussed the sexual abuse of children with Johanna Krout Tabin, whose book On the Way to Self1 4 has forced many of us to revise our

386

DONALD NATHANSON

concepts of the formation of gender identity, childhood sexuality, early ego structures, and the relationship of these issues to eating disorders. She commented (personal communication, 9 December 198 7) that when we discuss the way some adults engage in sexual behavior with children, it is not correct to call this abuse, for that word focuses attention on the adult to the exclusion of the child. It is axiomatic that the victim of rape is not a willing participant; yet the child who has been drawn into sexual activity with an adult is often quite excited by this activity and derives much pleasure from it. She suggests that these are examples of sexual exploitation, for by this term we note "the child's ambivalences in the situation without diminishing the adult's responsibility." It is the "overwhelming confusion about good and bad within the child as to its impulses" that produces such overwhelming shame and guilt and leads to disturbances in personality formation. Once again, whenever we feel that we are not in control of our bodily functions, we feel humiliated. It is difficult enough for an adult to relax into sexual excitement, to "let go," but for the child, being led by an adult into sexual pleasure can, like an enema, be experienced as humiliating loss of control at the hands of a trusted other. A friend in another city calls to ask advice: This busy couple, both occupied nearly full time with their own careers, had, like many of their peers, left their children in the care of a lovely and trusted woman who had become part of their own family. Realizing that his 3- and 7-year-old daughters did not want to be left at her home that day, he shelved the urgency of his own work to enquire gently and at length about their fears. Often, it seems, this woman would leave the children in the company of her 13-year-old son, who taught them the mixed pleasures of fondling and fellatio. Through his rage and grief, my old friend asked "Why did it take so long for the girls to tell us? Didn't (the boy) understand what would happen to him when people found out? Everywhere I look there are secrets." (Some years ago, when Daniel Ellsworth was testifying before the United States Senate, being asked why he leaked the "Pentagon Papers," I recall my surprise when he said "Wherever there is secrecy there is lying.") We discussed the secrecy inherent in shame and the delicacy with which he had to treat their disclosures. He too would be embarrassed later, when (as mandated by law) the inevitable therapists would make their inevitable report to the police, who would disclose yet another scandal to the newspapers and television stations, who would send reporters to invade further their privacy and magnify the shame of all involved. SOME SUGGESTIONS FOR THE CLINICIAN Here are some suggestions for the evaluation and treatment of people who have been abused or exploited: 1. Remember that shame attends both the one who has been uncovered and the one who uncovers. We can be equally embarrassed by what we learn in our role as therapists as the patient who describes to us the shaming scene. One of the reasons we therapists have been so

UNDERSTANDING WHAT

Is

387

HIDDEN

slow to understand the nature of shame and to develop sensible systems for the treatment of shame-based psychopathology is precisely this fact that whatever shame we uncover becomes our shared experience. This is neither countertransference nor our personal psychopathology. It is part of the nature of shame. 2. So complex is the layering of experience that turns each innate affect into a mature emotion that we never really know what another person means when using an emotion label. The initial phases of all psychotherapeutic interaction allow therapist and patient to develop a lexicon of emotion, to learn what each means when using the common words for emotions. Some people handle shame by withdrawal, some by anger, some by humor (accounting for the genre of anecdotes called "my most embarrassing experience") and others by stone-faced refusal to emote. When interviewing an abused patient or an exploited child be sure that you know what the other person means when using common words. 3. Try to find out how this particular person has defended against previous experiences of shame. Most people have pretty good systems for handling each emotion. Be careful not to expect the patient to use your own system, whatever it is, no matter how successful it has been for you in the past. As Morrison 9 has pointed out, the degree to which shame afflicts each of us is dependent on the degree to which we have been exposed to empathic failures in early life. The effectiveness of your sensitive, empathic treatment of sexual abuse and exploitation will depend on the adequacy of the patient's previous empathic experience. 4. Support the patient's own expression of embarrassment, whether in the form of anger, laughter, withdrawal, or tears. Only after you understand this person's characteristic mode of defense against shame can you mobilize the defensive system you believe to be more therapeutic. It may be morally important to you for this patient to confront his or her attacker in a court of law, but the patient cannot be brought to face the source of such terrible shame without the risk of further shame until allowed to understand the nature of the shame. 5. Shame has been ignored too long in our work. All of us must begin to read the new work on shame and learn to search within ourselves to gain understanding of our own relationship to shame at all of its layers. When we have come to understand the importance of shame in our own development, we will have achieved a new level of sophistication at all levels of therapy, especially in our treatment of those who have been exploited and abused in the private world of the sexual self.

SUMMARY Competence in treating the victims of sexual abuse and exploitation requires an understanding of shame, the complex and multilayered emotion triggered when we have been exposed or when our selfesteem has been reduced. The experience of shame is initially physiologic, involving a cortical shock momentarily halting higher cognitive

388

DONALD NATHANSON

function, but followed immediately by a host of associations to previous experiences of shame. Acutely, the affect itself impels hiding, while defenses against it include anger, humor, silence, and a wide range of behaviors. In our culture, all sexuality involves an interplay between exposure and privacy, between control and release. The sexual abuse of adults and the sexual exploitation of children must produce shame; study of the interaction between abuser and abused suggests that shame conflict figures prominently in the genesis of such activity. To the extent that psychotherapy itself involves exposure, it must trigger shame; thus, it is likely that the therapist unskilled in the recognition of shame in all its disguises will overlook or misunderstand many of the issues that should form the core of our treatment of those whose sexual selves have b een abused or exploited.

REFERENCES l. Anthony EJ: On the development of shame in childhood and adolescence. Paper presented at symposium on Shame: New Clinical and Theoretical Aspects, American Psychiatric Association, Los Angeles. May, 1984 2. Basch MF: Understanding Psychotherapy: The Science Behind the Art. New York, Basic Books, 1988 3. Broucek F: Shame and its relationship to early narcissistic developments. Int J Psychoanal 65:369 - 378, 1982 4. Edelstein E, Nathanson DL, Stone AM: Denial: A Theoretical Clarification of Concepts and Research. New York, Plenum, 1989 5. Fenichel 0: The Psychoanalytic Theory of Neurosis. New York, Norton, 1945 6. Kaufman G: Shame: The Power of Caring. (Revised Edition). Boston, Schenkman, 1985 7. Lewis HB: Shame and guilt in human nature. In Tuttman S, Kaye C, Zimmerman M (eds): Object and Self: A Developmental Approach. New York, International Universities Press, 1981 8 . Lewis HB: Shame and the narcissistic personality. In Nathanson DL (ed): The Many Faces of Shame. New York, Guilford, 1987 9 . Morrison AP: The eye turned inward: Shame and the self. In Nathanson DL (ed): The Many Faces of Shame. New York, Guilford, 1987 10. Nathanson DL: A timetable for shame. In Nathanson DL (ed): The Many Faces of Shame. New York, Guilford, 1987 11. Nathanson DL: The shame/pride axis. In Lewis HB: The Role of Shame in Symptom Formation. Hillsdale, New Jersey, Lawrence Erlbaum Associates, 1987 12. Nathanson DL: Project for the study of emotion. In Bone S, Glick RA (eds): Affect: Pleasure Beyond the Pleasure Principle. New Haven, Yale University Press, in press, 1989 13. Schneider CD: A mature sense of shame. In Nathanson DL (ed): The Many Faces of Shame. New York, Guilford, 1987 14. Tabin JK: On the Way to Self: Ego and Early Oedipal Development. New York, Columbia University Press, 1985 15. Tomkins SS: Affect/Imagery/Consciousness. Vol I and 2. New York, Springer, 1962, 1963 16. Wurmser L: The Mask of Shame. Baltimore, Johns Hopkins University Press, 1981 17. Wurmser L: Shame: The veiled companion of narcissism. In Nathanson DL (ed): The Many Faces of Shame. New York, Guilford, 1987

2403 Medical Tower Building 255 South 17th Street Philadelphia, Pennsylvania 19103