The Factor of Shame
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Shame is the air we breathe in addiction treatment. It suffuses what is said, which words are used to say it, and especially what is left unspoken. And because shame is so pervasive and entrenched in addiction work, it can be difficult to identify and distinguish from other related concepts. This week we are looking at how shame affects treatment and recovery efforts, as well as which aspects of what might be called "shame"– I'll argue they are actually something else– can be healing and constructive. While people harbor shame for all kinds of reasons, this post addresses shame around substance use and choices directly related to it.
Witnessing someone's shame in addiction is so intimate that it almost feels disrespectful to describe, even in the most general terms, what it looks like. People often speak in passive voice about things they have done of which they're ashamed, or become exceptionally vague, or leave out important information because it does not reflect well on them. This can, of course, make it difficult to do psychosocial treatment: What are we really talking about here? Are you saying what I think you're saying?
At this point, I can work with / around / through self-reports that I know are far from complete due to shame. I can imagine a pie chart, with a tiny slice of the full reality representing all that my client is willing to share (at least for now), and start there. Earlier in my career, I thought it was important to get all my questions answered– and my client relationships faltered as a result. This is one reason I no longer work with clients who are forced into counseling: in mandated treatment, you have to check certain boxes, pushing past the person's boundaries if that's what it takes. Often they are reticent to share due to legal concerns, but silence and evasions may also be due to shame. In voluntary counseling, I just work with whatever my clients bring. Treatment may still go nowhere, but at least we're not putting on an act for a third party authority.
What Shame Is And Isn't
For a therapeutic context, here are my working definitions for shame and some related concepts that may be mistaken for shame. For each feeling, after the arrow ➡️ comes the attitude toward self that tends to arise with it.
Shame: I am inherently bad, worthless, unlovable, unsalvageable. ➡️ I am not capable of change.
Guilt: I did something that I know is wrong. ➡️ I could do better.
Accountability: I own my actions and care about how I affect other people. ➡️ I reflect on what I'm doing, and I listen to feedback.
Shame, as you can see, is not only painful– it is also, for practical purposes, a dead end. If I have no value or potential as a person, change is not possible, so treatment or recovery efforts are a waste of my and everyone else's time. This is why shaming people with addictions, or even letting their existing shame go unchallenged, is so harmful and counterproductive. Shame can also feed into cop-outs in what I call addiction essentialism: the idea that all people with addictions share certain core problems of behavior and character. Nothing short of abstinence holds any hope for the "essential addict," and even in recovery, these flaws pose an ever-present threat requiring tight control. Giving up, and having others give up on me, might seem like a relief by comparison.
Rosalie Genova
Guilt, on the other hand, implies at least some degree of positive self-concept: I did something bad, but I recognize that (a point for my judgment) and expect better of myself (a point for my capability). I (Rosey this time) used to get annoyed when clients said of the things they did under the influence "That's not me." Then who is it, buddy? But compared to a shameful or essentialist attitude in which harmful conduct is totally predictable, even part of their identity, "that's not me" holds a lot of promise. What is it about these actions that does not reflect who you are? What kind of person do you intend to be instead?
Ultimately, accountability is the most constructive, proactive attitude toward one's self and one's choices. Addiction treatment or peer support interventions that come across as guilting or shaming may really be intended to foster accountability. And when someone already feels guilty or ashamed, I find they can often be nudged toward an accountability framework in which they know better, are capable of better, and care to do better– if not for themselves, then for people they care about. This is more of a challenge to them than either superficial assurances, at one extreme, or writing off at the other. It is an invitation to "any positive change," which is one of my favorite definitions of recovery, and helps people improve their own processes for making and evaluating choices.
📅 Save the date: Monday June 22 I'm teaching another online Continuing Ed class on moral injury in clinical work. Details are still being finalized, but it should be 6 CE Ethics credits, and affordable– like, last time it was $10. I will post the link to register when it's available, but these fill up fast, so get on the CCSME mailing list if you want to be first to know. I'd love to see you there!
