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Teach shame resiliency during recovery for better results

August 7, 2015
by Julia Brown, Associate Editor
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The most effective trauma resolution and addiction recovery work will not last if shame is bypassed during treatment. In fact, bypassing shame can often fuel an addiction, said Katie Thompson LPC, NCC, CEDS, at the National Conference on Addiction Disorders (NCAD).

Shame must be identified and addressed as one of the roots of addiction, she added, and teaching patients shame resiliency will allow them to make better strides in treatment.

What is shame? 

“Shame is the intensely painful feeling or experience of believing we are flawed and therefore unworthy of acceptance and belonging," according to Brené Brown, scholar, author, speaker, and shame and vulnerability expert.

Shame is often used in society as an agent of change without realizing how much damage it does, Thompson said. While everyone has healthy shame—an emotion tied to guilt that signals our moral compass and limits around right and wrong—there are types of guilt that aren’t healthy. Those include toxic shame, shame spirals and shame webs.

Toxic shame is believing that the whole self is fundamentally flawed and defective to the point were the self becomes an object of contempt. It's tied to all feelings, and the state of being “shame-bound” becomes an intolerable state of being for the patient. 

Thompson likened toxic shame to a funhouse mirror, or the patient having an image of one’s self that is distorted by abuse and abandonment. Toxic shame is also highly connected to trauma. 

shame spiral is the recycling of toxic shame that’s difficult to step out of, and is often accompanied by a victim stance.

Shame webs are layered, conflicting and competing social expectations (who, what, how one should be). Entanglement in a shame web causes fear, blame and disconnection within a patient that creates shame.

Thompson said the most common shame categories are appearance and body image, money and work, motherhood/fatherhood, family, parenting, and mental and physical health—including addiction and surviving trauma—and the development and internalization of these types of shame must be understood. 

Addiction as a mediator, false protector and prophet 

Shame often functions to protect a person from the world witnessing their perceived defectiveness, she added, which acts as a barrier during recovery. When a patient has shame, they also often have no resolve reinforcement for breaking an addiction.

For a shame-bounded person, the addiction often "steps in" to protect them from the pain of cycling shame and numbs them to it, said Thompson. For example, the addiction can be used to guard the person’s truth about feeling defective, protect them from those beliefs, change their perceived "badness," hide their defectiveness, etc. And the behavior is cyclical. Like an overflowing bucket, the addiction produces more shame that gets added to the person’s reservoir that fills up and pushes the person into a shame spiral.

“While it protects, it simultaneously destroys,” she Thompson said. "The addiction only reinforces their original beliefs rooted in shame, and as a result, the person loses connection, is isolated and cannot function in life."

Resiliency in recovery

During recovery, patients typically have three layers: addiction (outer), shame (middle), and trauma (inner), she said, and the most effective trauma resolution will not last if shame is bypassed.

“It’s like attempting to consume the flesh of an apple first without consuming the peel,” Thompson said. Using basic dialectical behavioral therapy and bypassing shame actually made addiction stronger and had clients symptom swapping, she added. 

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Enjoyed "shame resiliency" article. Very much enjoy exchanging thoughts on AP website. I've done some training with our staff on being careful that we don't create or add to shame. A few excerpts below.
Michael Weiner, Ph.D., CAP (mweiner@seasidepalmbeach.com)
Shame: We didn’t intend to create it.
The first publication created by Behavioral Health of the Palm Beach (BHOP)’s Research Department was an outcome study published in 2006. We did the best we could. We had to trust in people’s honesty. It was often hard to track people down. The result of our best effort indicated that 53% of the people remained substance free one year after leaving residential care at BHOP. We did an honest job. A fifty-three percent success rate seemed reasonable. We were pleased with ourselves.
We never really paid attention to the finding that 47% of the patients we contacted were labeled “failures.” You were either a “success” or a “failure.” There was nothing in between. After all, it was a study designed to determine our “success rate.”
Creating” treatment failure” led me to start thinking about and paying attention to other ways that we may have unintentionally created shame. Unfortunately, I found a few.
• As a profession, we are the only group that has expected perfection as the only measure of success. If professionals treating diabetes used 100% stable blood sugar levels as their measure of success their success rate would be zero.
Thankfully, we are moving forward

• Neither SAMHSA (2012) nor the American Society of Addiction Medicine (2013) includes abstinence from substance use as a measure of recovery. ASAM defines recovery as “A process of sustained action…….. in the direction of consistent pursuit of abstinence.” So, as long as a patient is still seeking abstinence they’re still in the game.

• We tell our patients that they have a chronic disease but we use acute care models. Acute care language has become the language of shame.
1. We’ve all heard patients say “I’ve been to treatment before.” Are they saying “I’ve failed before?” It has to feel bad. It has to feel shameful. I wonder what it feels like to say “I’ve been to treatment three times before?”
You know what makes me feel worse? When I think about how many times I’ve asked a patient “how many times have you been in treatment?” What am I really asking? The implication is “how many times have you failed?”

2. What a person has learned “in the consistent pursuit of abstinence” is important and needs to be taken into account when a patient with a history in recovery re-engages into a higher level of care (assuming that we consider that a patient has been engaged in a lifetime process).

It is true that within 12-step recovery a patient would be encouraged to pick up another white chip signifying that the recovery process has begun again. Even within 12-step circles picking up another white chip has been referred to as “the walk of shame.”
It is up to us to encourage a person to perceive it as a “welcome back” gesture.

3. We need to get better and take responsibility for motivating our patients. We don’t throw people away...
We can get better at motivating our patients and it is important that we do.
We convey the message that “you better get well fast in the way we want you to do it or we don’t want anything to do with you.” We have made statements like “come back when you’re ready,” or “you need to do more research.”
Would any one of us have made such a statement to a person with any other disorder?
Similarly, I’ve often heard the expression,” I’m not going to work harder on your recovery than you are.”
On the other hand, we generally expect a patient to be in denial and ambivalent about recovery. So we expect a patient who is in denial of their disease and probably doesn’t really want to be in treatment in the first place to work hard? We can’t have it both ways.

It is also important to remember that 12-step recovery is to be respected. We may have to teach patients how to cope with aspects of 12-step recovery that can be shameful (“walk of shame”) but there is no support out there that approaches what 12-step recovery can do and has done.
Being respectful is part of recovery.

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