June 02, 2016

Managing Shame and Emotional Pain in Eating Disorder Recovery – Aimee Keith

group of friendsShame is an important, and often neglected, emotion that is present in many patients with eating disorders.

This is especially true in patients who strive for perfection and feel they are far below the standards that they have imposed on themselves or perceive to have been imposed upon them.

The difference between guilt and shame

Shame is often confused with guilt, but here is how the two differ:

Guilt — Guilt is the feeling of remorse for an action performed by an individual. Guilt tells us that our behavior was bad.

Shame — Shame takes the feeling of guilt and intermixes it into our very being, and tells us that it’s not just our behavior that was bad, but that we, deep down in our very core, are bad, defective, and unworthy of love and acceptance (Dearing and Tangey, 2014).

Guilt can be solved through confession of our wrongs and the seeking of forgiveness. Shame, on the other hand is not resolved in this way. Instead, it lingers as the voice that says, “You are too bad to be loved.”

Shame and eating disorder behaviors

Many patients that struggle with eating disorder behaviors have been shamed both directly and indirectly in their lives. For example, an invalidating environment indirectly says, “Your emotions are wrong and you are wrong to have them.” Sadly, when this occurs, patients soon become very good at invalidating and shaming themselves. This can lead to avoidance of emotions which may only be numbed through ineffective and destructive behaviors such as restriction, binging/purging, self-injury, substance use, etc.

How to overcome shame

Many patients in therapy who feel shame experience an intense urge to hide. This can be as simple as breaking eye contact with the therapist, changing the subject, or covering the face. It can also be as extreme as a complete dissociation, avoiding others or avoiding treatment altogether (Stadter, 2014).

Shame is often not addressed and therefore has more power: it will guide the thoughts and emotions of the patient. But, if a patient can stay in the therapeutic relationship and allow a glimpse of their perceived badness, they are given the chance to have their badness loved and accepted. This proves the inner voice that says, “You are too bad to be loved” wrong!

When shame rears its face in a therapy session, we must draw attention to it. We can invite the patient to allow their whole selves to be seen in the safe space of therapy.

Feeling worthy, in spite of shame

Shame is a powerful emotion. While it often remains hidden, we can help our patients recognize it, label it and distinguish it as separate from guilt. We can teach our patients to tolerate shame without acting on their safety behaviors of hiding and avoidance.

While we can never cleanse a patient of all their shame, if we pay attention to it, we stand a chance of removing some of the power of that inner voice that questions the lovability in all of us.

Aimee Keith, PsyD is a Postdoctoral Intern & Primary Therapist I at ERC’s San Antonio location. Dr. Keith is also a Content Expert for the MATR program and BETR program.

  • Dearing, R. L. and Tangney, J. P. (2014). Introduction: Putting shame in context.” (pp. 3-19) in Shame in the Therapy Hour. Edited by Dearing, R. L. and Tangney, J. P. American Psychological Association, Washington DC.
  • Stadter, M. (2014). The Inner World of Shaming and Ashamed: An object relations perspective and therapeutic approach.” (pp. 45-68) in Shame in the Therapy Hour. Edited by Dearing, R. L. and Tangney, J. P. American Psychological Association, Washington DC.  
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