Shame in the Clinical Process with LGBTQ Clients

Abstract

This commentary integrates the literature on the social and psychological dynamics of shame and discusses its relevance to the clinical process, especially with lesbian, gay, bisexual, and transgender and queer clients. It is argued that engagements with shame, especially where sexual desire, sexual orientation, or gender identity is a foremost consideration or conflict, may be the most important factor in producing and maintaining the therapeutic alliance. Shame, a social emotion, is considered in the light of work done in sociology, psychology, neuroscience, and psychoanalysis. Future directions for clinical research are suggested.

Full text

COMMENTARY
Shame in the Clinical Process with LGBTQ Clients
Jeffrey L. Longhofer
Published online: 19 July 2013
ÓSpringer Science+Business Media New York 2013
Abstract This commentary integrates the literature on
the social and psychological dynamics of shame and dis-
cusses its relevance to the clinical process, especially with
lesbian, gay, bisexual, and transgender and queer clients. It
is argued that engagements with shame, especially where
sexual desire, sexual orientation, or gender identity is a
foremost consideration or conflict, may be the most
important factor in producing and maintaining the thera-
peutic alliance. Shame, a social emotion, is considered in
the light of work done in sociology, psychology, neuro-
science, and psychoanalysis. Future directions for clinical
research are suggested.
Keywords Shame Stigma Therapeutic alliance Social
emotions Working alliance Therapeutic engagement
In this commentary I will consider key themes that have
emerged across the spectrum of the social sciences—neu-
roscience, sociology, phenomenology, psychoanalysis, and
clinical practice—with special attention paid to under-
standing the social and psychodynamics of shame and
sexuality, which for me seem essential in a special issue
that discusses clinical practice with lesbian, gay, bisexual,
transgender, and queer (LGBTQ) clients. What kind of
emotion is shame and as a special kind of social emotion
how does it function to limit or organize our sexual and
social lives? And what do the various disciplines have to
teach us about the relationship between shame and sexu-
ality? Here, I will comment on and integrate, not review,
the vast literature on shame. I will offer, incorporating
ideas from several disciplines, observations about the
management of shame in our understandings of sexual
desire in the clinical process; more specifically I propose
that our clinical engagements with shame, especially where
sexual desire is a foremost consideration or conflict, may
be the single most significant factor in producing and
maintaining the therapeutic alliance, enactments and
impasses (Horvath and Greenberg 1994; Safran et al.
2001). Indeed, I have long believed that because our
measures (i.e., standard scales) of the strength of the
therapeutic alliance do not include shame dynamics, we are
in all likelihood missing one of the key variables in
understanding the establishment, development, and main-
tenance of the alliance. I begin with a very concise
description of the social emotions and shame. With equal
concision, I look at some of the common concerns in the
broader literature on shame and conclude with a few
thoughts on future directions for clinical research.
The Social Emotions Defined: Shame
Shame is counted among the so-called social emotions.
Though not without controversy, including my own skepti-
cism, researchers often describe two fundamental categories
of emotion, basic and complex (Ekman 1992). The complex
ones, also called secondary or derived, emerge later and
depend on specific developmental achievements (i.e., cog-
nitive, self/other differentiation, and conscience develop-
ment). The social emotions, moreover, require the capacity
for representation of mental states (e.g., embarrassment,
guilt, shame, and pride), which are closely indexed to the
emergence of social cognition, that is, the ability to imagine,
perceive, and act on the mental states of others.
J. L. Longhofer (&)
School of Social Work, Rutgers, The State University of New
Jersey, New Brunswick, NJ 08901, USA
e-mail: jlonghofer@ssw.rutgers.edu
123
Clin Soc Work J (2013) 41:297–301
DOI 10.1007/s10615-013-0455-0

The Oxford English Dictionary offers the following
definition of shame, ‘‘painful distress or humiliation,’’ and
mortification as ‘‘great embarrassment and shame.’’ In my
clinical work with LGBTQ clients I have imagined a shame
continuum (i.e., what I call the social and psychological
dynamics of shame) that runs from mild forms of embar-
rassment (i.e., mostly under cortical influence, language
and meaning-making) to greater and greater disability (i.e.,
mostly under the influence of the subcortical regions),
toward humiliation and finally, to mortification (Kilborne
2002; Lansky 2007). And while stigma may under partic-
ular circumstances (e.g., family rejection; see LaSala, this
special issue) produce shame, even mortification, the con-
nection between the two is entirely contingent and should
always be the object of empirical inquiry. And while this
relationship is contingent, shame is for me only a potential
psychological outcome of stigma; only careful inquiry
(especially in the clinical setting, over time) can establish
the degree of relationship and effect.
As one moves along the continuum toward mortification,
cognition, behavior, and emotion are increasingly under the
influence of subcortical and somatic responses. In sum,
shame, guilt, embarrassment, and pride belong to a family of
social emotions: ‘self-conscious emotions’ that are evoked
by self-reflection and self-evaluation. Self-evaluation,
moreover, may be consciously experienced or outside
awareness. And the degree to which it is out of awareness, the
more it will be expressed in bodily ways and experienced in
the clinical setting. Moreover, if there are conflicts over or
concerns about the ‘‘normality’’ of the body and body feel-
ing, the more likely shame will be experienced as mortifying
(Janicki, personal communication, 2002) and manifest on the
skin surface. It is in the therapeutic encounter where the
potential for increased exposure to shame (this is no doubt
true in all social work settings and engagements) is most
likely to lead to a rupture in the working alliance or to rec-
ognition and a deepening of the engagement.
Finally, shame is first and foremost a somatic event. It is
initially experienced and mediated through the automatic
nervous system and signaled by the body; thus, the more it is
perceived and observed, the more it is sensed, especially in
the therapeutic setting (Dearing and Tangney 2011). It
appears that shame (Schore 1994; Dickerson et al. 2004), like
fear (LeDoux 2003a,b), is processed through the primitive,
subcortical part of the brain, the limbic system: amygdala,
hypothalamus, and thalamus. When one feels shame one
lights up, one cannot stop the physiological response: the
blushing and bodily transformations. And acute shame for-
ces us out of language and directly into the body.
Understanding the somatic dynamic of shame is espe-
cially important in working with LGBTQ clients as some
may bring their bodies into the clinical encounter feeling
damaged, flawed, and rejected. One cannot talk themselves
out of these profoundly shame-saturated states. And
because both fear and shame are processed in these centers
they share a fundamental similarity: no cortical involve-
ment, no symbolic representation, no words; there is only
bodily response of fight, flight, or freeze: the hiding of pain
and lament. Moreover, with pride the sympathetic nervous
system is at work: high levels of arousal, activity, elation,
and decreased peristalsis, whereas with shame, the para-
sympathetic nervous system dominates (i.e., low energy,
gaze aversion, reduction in muscle tone (i.e., loss of smile),
blushing, and increased peristalsis). While Collazo, Austin,
and Craig (this issue) bring our attention to the body and
shame dynamics related to gender transitioning, there is so
much more to learn about the shame continuum in working
with those in transition.
It would be almost impossible to consider our current
understanding of shame without mention of the important
contribution of the psychoanalyst, Lewis. And even though
her work remains unacknowledged (especially in fields
unrelated to psychoanalysis), you can sense the large foot-
print of her ideas (see Lansky 2007). And while there is now a
very extensive and significant psychoanalytic literature on
shame (Lansky 2007), it was Lewis (1971) who first dis-
cussed the role of shame in symptom formation, especially
when it is repressed or denied. Reminiscent of how anthro-
pologists once regarded and generalized about cultural styles
(i.e., guilt vs. shame-based cultures), Lewis argued that we
are governed by differing affective styles (i.e., shame-
proneness or guilt-proneness) that yield degrees of shame or
guilt experience that, in turn, produce varying psychological
symptoms. There is much research and clinical investigation
to be done (driven by case study methods) on the relationship
between the experience of shame and sexuality in specific
cultural settings (i.e., cross-culturally, in sport, work envi-
ronments, schooling) and how these settings affect well-
being, performance, and capabilities (Sayer 2005).
Shame and the Social Sciences
The disciplines of sociology and psychology have paid
considerable attention to shame. In sociology, the schol-
arship on shame can be easily organized into commu-
nitarian/functionalist (e.g., Scheff 1988,2000,2003),
phenomenological (e.g., Katz 2001), and critical realist
(Sayer 2005) schools; however, critical realist scholarship
will not be discussed in this commentary. And while
anthropologists have in recent years paid less attention to
their once historical claim to the subject Wong and Tsai
(2007) offer a more recent and compelling discussion of
the anthropology of shame and guilt. Though I will not
suggest a possible strategy in the few pages of this com-
mentary, it will become clear that one might further
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organize thinking about shame into two additional cate-
gories: grand theory and experience-near accounts.
Grand Theory of Shame
In 2000, the communitarian sociologist Scheff offered a
grand theory of shame in Shame and the Social Bond:A
Sociological Theory. For Scheff, like most theorists of the
social emotions, shame is especially significant because it
results from viewing the self from the perspective of the
other. Understandably, Scheff and others in sociology
turned to Cooley and the symbolic interactionists to con-
ceptualize this self/other dynamic of shame. As well, like
most theorists, social and psychological, Scheff sees shame
as a negative evaluation of the self by the self; likewise,
pride is a positive evaluation by self or others. Other
researchers have similarly conceptualized shame and pride
as reflexive affects, involving negative and positive self-
attention (e. g., Nathanson 1987).
Scheff (2000) also borrowed extensively from Lewis
(1971,1987) to establish his case for the overarching role
of shame as an organizing emotion, even, perhaps, the
central emotion responsible for securing and maintaining
the bonds necessary for social life. In short, for Scheff,
shame or the anticipation of shame, pervades all social
engagements: ordinary, everyday, cooperative ones, and
those rife with tension and conflict. Scheff borrows from
Irving Goffman the idea of ‘impression management’ and
argues that for Goffman avoidance of shame is the moti-
vating force for the management of impression: anticipat-
ing, experiencing, and managing shame thus governs social
life and human interaction.
For those working closely with LGBTQ clients, it is
more than clear that much psychic energy is expended in
impression management, and that defenses are sometimes
rigidly built up around the need for this management.
Shame, moreover, especially for those precariously per-
ched on the enunciation of their desires (to self and other)
may signal both a potential threat to the social bond and
one’s position in any given relationship. LaSala (this issue)
and Hash and Rogers (this issue) point indirectly to the
shame that results from societal rejection and call for
elaboration of therapeutic models that are sensitive to this
dynamic. Where the subject is exposed or forced out of the
closet, the potential threat to the social bond may even
produce mortification. Whereas pride may signal a secure
bond, shame points to threatened or damaged ones. With
pride there is the potential for solidarity and connectedness,
with shame a sense of disconnectedness. There can be no
doubt that in working with clients struggling with gender
identity and sexual desire that this sense of loss of con-
nection must be attended to, not just in the transference, but
also in reality (see Collazo et al. this issue, for discussion of
how relationship loss is experienced). Furthermore, these
connections might be just as easily reestablished in work-
ing outside the transference, especially as a developmental
object, so that shame, if it is well established (i.e., toward
mortification and physical pain), can be reworked and the
somatic responses can be brought under increasing control
of cortex (i.e., executive functions).
There’s one very important implication of communi-
tarian thinking about shame. If shame is an organizing
emotion and crucial for social life, what becomes of pride
in modern society? For pride, the signal connection with
the other, is rare, and due to pervasive alienation and
micro-aggressions and humiliation in everyday life (in
schools, work, and family life), we are left with few
memories of or authentic feelings of pride. Scheff has been
especially interested in how this dynamic allows one to
translate shame language into relationship language. In
light of this understanding of pride, I am left to wonder
about one of the key conclusions drawn from the quite
important 2003 Gay Shame Conference held at the Uni-
versity of Michigan. The conference marked and summa-
rized a moment in the history of gay and lesbian
scholarship in the humanities: the struggle to understand
how exclusion works and how shame functions to both
mobilize and foreclose forms of desire in potentially pro-
ductive and transformative ways. Pride, for some, is not an
available emotional state and may under some circum-
stances lead to further marginalization for those not readily
incorporated into LGBTQ identities or social movements
(Halperin and Traub 2009). I think we often engage with
LGBTQ clients who easily fit into this category. Just as
often clinicians will talk about the ‘‘coming out process’’ as
if it were a teleology leading naturally and ineluctably to a
reduction in shame, an increase in positive identifications,
and reincorporation into an imagined but sometimes unreal
and unrealistic communities. Thus, we should also attend
in our clinical work to those seeking to transform shame
into other mental states without assuming that pride is the
necessary outcome; and when there is a failure of pride to
instill identity and produce communal possibilities, we
must be able to offer the services necessary to provide safe
and secure spaces for human flourishing (Sayer 2011).
Experience-Near Accounts of Shame
In what way is shame a self-conscious emotion? Katz, a
sociologist working within the phenomenological tradition,
answers this question by focusing very carefully on how we
experience shame. Katz, the author of a very interesting but
not often-enough cited book, How Emotions Work (2001),
eschews grand or totalizing theories of shame. Instead, he
examines the lived experience of shame: experiential,
subjective, and creative. He is especially interested in
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behaviors that provoke and are thus associated with emo-
tions. For example:
Acting mean, I provoke you to give me an excuse to
attack you. By contorting my face into the outlines of
crying, I elicit from you a hug that enables me to
break down completely. Such understandings
between feelings and expressive behaviors are part of
the universally shared but private psychology on
which people shape the idiosyncrasies of their per-
sonal identities (Katz 2001, p. 144).
For Katz, if there is a behavior clearly associated with
shame, it is the inability to respond, or to respond in exclu-
sively bodily ways (i.e., sweating, blushing). And unlike
shame, other behaviors—laughing, crying, anger—are
clearly associated with specific provoking feelings; data on
anger, for example, can be derived from direct observation of
interactions. The study of shame, however, because it lacks
this observational immediacy, according to Katz, requires
that we use methods to capture the actual experience of
shame; in short, it must come from those who experience
shame. This may explain, in part, why psychoanalysts offer
the most nuanced experience-near accounts of shame (Kil-
borne 2002; Lansky 2007; Siebold 2008) and why literary/
cultural theorists offer the most experience-distant accounts,
and also why sociologists and other social theorists often turn
first to psychoanalytic accounts and ideas.
With the experience of shame, moreover, ‘‘others’’ need
not be present. And it is with this observation that Katz
(2001) further differentiates crying, anger, or laughter,
from shame. These behaviors, unlike shame, involve
action. With shame, a more passive state, the more one
reflects, the more one feels shame. The study of emotions,
Katz argues, requires methods that attend to this intrinsi-
cally temporal dynamic: shame is always unfolding. Cross-
sectional, synchronic, or time-limited data obscure this
essential nature of emotion: its changing, unstable, and
fluctuating quality. In the clinical encounter, from the
moment the client crosses the transom into the consulting
room, shame is a potential, if not necessary, first, inter-
subjective encounter: ‘‘what kind of person am I that is
needing to see you, a therapist, a social worker?’’ And for
those entering the room marked in other ways by same-sex
desire or gender expression, the potential for shame to
define and limit the engagement is almost without excep-
tion. Many therapists can recall a client unable to enter the
consulting room, paralyzed, filled with shame, even mor-
tification, unable to find words, averting gaze, seeking
every possible means of avoiding exposure. How to name
and process these mental states in the establishment of the
working alliance is an uncertain and difficult task that
involves a quiet and sensitive presence, a sort of passive
listening to how difficult it must be to enter the room.
Katz (2001) describes three dimensions of the shame
experience. The first he calls metamorphosis. In this
dimension, the subject of shame is in an especially unsta-
ble, wordless, chaotic, humbling state and seeking alter-
native emotional registers for the expression of feeling; or
to altogether escape notice and disappear. Based on the
work of Helen Lewis (1971,1987), Katz describes shame
as holistic, that is, it refers not to a part but to the whole
self. Lewis (1987) proposes that:
Shame is about the whole self. It is possible in
moments when one is not ashamed to regret or grieve
over a specific disfigurement or personal failing. At
the moment when one is ashamed of specific short-
comings, shame affect involves the whole self (p. 15).
In the second dimension, what he calls the ‘‘interpre-
tive,’’ the subject is profoundly but uniquely exposed: but it
is an exposure of the self to the self, and while it may
involve the response of others to the self, there may be no
face-to-face interaction whatsoever. And in these uniquely
self-reflective, unfolding moments, one is completely iso-
lated, deprived of membership in the social order: in the
community but not of the community (Katz 2001). In the
final and third dimension, what Katz calls ‘‘impotent
practice,’’ the subject is uniquely ineffective, morally
inferior, vulnerable and subject to what seems an inevitable
force: morally inferior because of a felt inability to engage
in proper conduct, vulnerable because of the felt sense that
one’s fate is out of one’s control.
I think it is possible to work with LGBTQ clients using
this phenomenological account of shame, beginning with
metamorphosis. Here, the subject may feel that the self is
swallowed up by the most illicit desire and in whichever
way that desire has been constructed, it refers to the whole
self, not to a part of the self. Here, the work is to narrow the
widening scope of shame and to bring it within reality: we
are not our desires, we are more than our desires, we are
also our needs, we are many and intersecting selves with
many possible and sometimes contradictory identities.
Conclusion
Our clinical work with LGBTQ clients must be governed
foremost by sensitivity to shame dynamics, both in its
social and psychological dimensions. Here, the argument
has been made that shame is located on a continuum from
mild embarrassment to utter mortification (i.e., the wish to
die, or disappear). There is significant clinical research to
be done, especially using the case study. For example, to
my knowledge there is no significant research on how
shame is differentially experienced (in the clinical setting)
by those in and out of the closet. Further research might
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show that many leading fully ‘‘out’’ lives experience shame
at the same or similar levels as some living in the closet.
Finally, I have suggested that the shame experience is best
accounted for in a transdisciplinary way, using anthropol-
ogy, sociology, psychology, psychoanalysis, and espe-
cially, phenomenology. I have pointed in some important
and new directions for research, especially toward more
nuanced and phenomenological accounts of the relation-
ship between stigma and shame, as this may help therapists
work more effectively with LGBTQ clients.
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Author Biography
Jeffrey L. Longhofer Ph.D., LCSW, is an associate professor of
social work at Rutgers University, where he also directs the Tyler
Clementi Center. He holds graduate degrees in anthropology and
social work. After finishing his degree in social work at Smith College
in 2002, he completed postgraduate training in child development and
psychoanalysis and adult psychoanalysis. He finished a book (2010)
for Columbia University Press: On Having and Being a Case
Manager:A Relational Method for Recovery. His second book
(2013), with Oxford University Press, ‘‘Qualitative Methods for
Practice,’’ offers an argument for why qualitative methods should be
used to study mental health practice in open systems (with Jerry
Floersch and Janet Hoy). His third book, under contract with Palgrave
MacMillan, A to Z for Psychodynamic Practice, will be released in
2014. He has served as the associate editor for the Society for Applied
Anthropology journal, Human Organization, and the International
Journal of Psychoanalysis and as editor of the American Anthropo-
logical Association journal, Culture and Agriculture.
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