Hiding Shame – A Case Study of Developing Agency

Abstract

The hiding aspect of shame makes the study of shame difficult. In this article we aim to show through Hanna's case study how shame manifests and develops during the course of one psychotherapy process. This will be done using Assimilation analysis (APES) and Dialogical Sequence Analysis (DSA) to show in detail one idiosyncratic developmental path through which the relationship toward the problematic shame experience changes and develops in psychotherapy. Results show how the manifestation of shame toward the problematic experience of being seen was present in the first moments of the first meeting, but also how during the sequence of sessions 7-9 Hanna's relationship toward shame evoked referent unveils and developed gradually through therapeutic work from assimilation stage 2 to reaching stage 5-6 at the end of the 9 th hour. This study shows how Hanna was able to reach a new kind of active agency toward the shame that, in the beginning, held the agency in her 'community of voices', and how this understanding of shame's developing and hiding nature can be of use in a clinically meaningful way.

Full text

85
DOI: 10.2478/rjp-2020-0008
Rom J Psychoanal 2020, 13(1):85-116
Rom J Psychoanal
HIDING SHAME – A CASE STUDY OF DEVELOPING
AGENCY
Sami Kivikkokangasa11, Mikael Leimanb,
Aarno Laitilac &William B. Stilesd,
Abstract: The hiding aspect of shame makes the study of shame
dicult. In this article we aim to show through Hanna’s case
study how shame manifests and develops during the course of
one psychotherapy process. This will be done using Assimilation
analysis (APES) and Dialogical Sequence Analysis (DSA) to
show in detail one idiosyncratic developmental path through
which the relationship toward the problematic shame experience
changes and develops in psychotherapy. Results show how the
manifestation of shame toward the problematic experience of
being seen was present in the rst moments of the rst meeting,
but also how during the sequence of sessions 7 – 9 Hanna’s
relationship toward shame evoked referent unveils and developed
gradually through therapeutic work from assimilation stage 2 to
reaching stage 5-6 at the end of the 9th hour. This study shows how
Hanna was able to reach a new kind of active agency toward the
shame that, in the beginning, held the agency in her ’community
of voices’, and how this understanding of shame’s developing
and hiding nature can be of use in a clinically meaningful way.
Keywords: shame, secrets, agency, DSA, assimilation analysis.
11 aDepartment of Medicine, University of Helsinki, Helsinki, Finland; bDepartment of Psychology,
University of Eastern Finland, Joensuu, Finland; cDepartment of Psychology, University of Jyväskylä,
Jyväskylä, Finland, dDepartment of Psychology, Miami University, Oxford, Ohio, USA; Appalachian
State University, Boone, North Carolina, USA; Metanoia Institute, London, UK.
Corresponding author contact details: Sami Kivikkokangas, Oskelantie 5 C 23, 00320, Helsinki; email:
sami.kivikkokangas@protonmail.com, phone +358406477130
Acknowledgements: This work was supported by the Finnish Cultural Foundation, Gyllenberg
Foundation and The University of Helsinki Funds under the Grant of the rst author.

86
1. Introduction
Shame is familiar to us all, but it escapes easy denition (Tangney,
1997). It can’t be seen directly, it is bypassed (Block-Lewis, 1971), or it
becomes visible only indirectly through the anticipated response of the
other (Bahtin, 1984, 1991). This hiding aspect of shame makes it dicult to
recognize in clinical encounters and in empirical studies. In this study we show
how shame can be observed in psychotherapy by tracing its development and
transformations using two qualitative methods in the intensively studied case
of Hanna (Kivikkokangas, 2017).
Classically, shame is regarded as a self-conscious feeling, which is easily
evoked when we face shaming, contempt or ridicule in interaction with an
external other or an internalized other. The rejecting answer of the other feels
like a problematic emotion in self-experience, something that needs disposing
of. One must also avoid exposing what privately evokes shame in a social
eld. The experiential core of shame builds upon unlovability, where dirtiness,
faultiness and worthlessness constitute the main pains of self-experience
(Wurmser, 1983). Shame is private, it needs to be kept hidden and that is why it
is everywhere and nowhere (Hästbacka, 2013, personal communication).
In psychotherapy, shame can function as an obstacle to the development
of self-observation in the presence of the other. The vulnerability inherent
in shame can prevent the step to enter into a developmental relationship
(Tähkä, R., 2000; Ikonen & Reckhardt, 1994; Lewis, 1971). The act of trying
to establish and seek connectedness to another might feel too dangerous or
revealing if the history is built on disappointments in reciprocity. It takes
courage to enter into a developmental relationship: how to be courageous
enough to enter into a relationship in a way that actively seeks connectedness
and reciprocity with the other, where the answer of the other is not under
my control or omnipotence – but depends on the other’s response. Instead of
seeking for reciprocity it is easy to cling on to a sadomasochistic, e.g. self-
ridiculing, way of relating to others or retreat from relations altogether. At the
same time the problematic nature of shame points to a conclusion: what has
been integrated in relation to another as unmet needs to be brought back to the
relational experience eld in order to be met and understood in a new way.

87
The hiding aspect of shame makes its ‘showing’ problematic. This is
implied in the previous models on shame (Lewis, 1971; Wurmser, 1983;
Ikonen & Reckhardt, 1994; Siegel, 2015), where concealment as a response
to feeling ashamed in front of other/s makes the investigation of the emotion
word challenging. Shame is often indirectly expressed. When you can call
shame a ‘shame’ (as a self-conscious feeling), it might be argued that it is
no longer shame (in the way it has previously kept the person hidden from
others and oneself). At its core is shame then a self-conscious feeling or, the
exact opposite, an unconscious feeling? The availability of the entire data set
enables the researcher to identify shameful experiences later in the therapy
and then follow the development of the gradual unveiling of the nature of
events from the beginning of the therapy. In this way we can see how shame is
expressed indirectly or warded o in the beginning of the therapeutic process,
where we don’t know what the concealment is directed at, but how we can
gain understanding about the nature of events about the shameful experience
through therapeutic work.
Assimilation of Shame
The assimilation model conceptualizes the psychotherapy outcome as
a change in relation to a particular problematic experience rather than as a
change in the person as a whole (Stiles et al., 1990, 1991). In the assimilation
model the patient’s relationship towards the problematic experience goes
through a sequence of developmental transitions in which the relation and
awareness of the problematic experience can change from being warded
o to being integrate into the total personality. This developmental process
is described in the eight-stages of assimilation of problematic experiences
sequence (APES), which are listed in the Method section.
At the beginning of therapy, the patient’s problematic experience can
match any assimilation level and any movement up the scale can be regarded
as progress. Research on the APES has shown that successful assimilation of
problematic experience does not proceed in a standard or linear way, particularly
because clients frequently shift from one strand of a problem to another, and
strands are assimilated at dierent rates (Caro Gabalda & Stiles, 2013).

88
2. Research aim and design
The aim of this case study was to investigate how shame manifests itself in
the clinical hour. The research question was: How is the problematic experience
of shame manifested in the patient’s utterances, and how does the relationship
toward the shame-evoking referent develop and change during psychotherapy?
To study shame experiences in the patient’s utterances and their
development across sessions, we used assimilation analysis (Stiles et al., 1992;
Stiles & Angus, 2001) and dialogical sequence analysis (DSA; Leiman, 1992,
2006, 2012) in combination. These two qualitative methods are described in
later sections. Assimilation analysis was used to describe and conceptualize
the development and change toward problematic experiences on the individual
level. DSA, as a microanalytical method, was used to analyze self-observation
and utterances. The combination of assimilation analysis and DSA has been
used successfully in previous research (Tikkanen, 2015; Leiman & Stiles,
2001). To our knowledge, this study is the rst to use modern microanalytic
methods to investigate shame in the clinical hour.
3. Method
Patient, Therapist and Case Materials
The patient, named Hanna, is a middle-aged woman, who sought
psychotherapeutic help for binge eating and worsened psychic health due
to traumatic life experiences. Her case forms an intensive case study that
has been approached previously from the viewpoint of working through
dierent emotions (Keto, 2010) and therapeutic interaction. Keto (2010)
concluded that the therapy progressed through dierent phases, where only
after sucient working though of emotional numbness and guilt, it became
possible to focus on feelings of shame. In addition, Keto (2010) pointed out
a how it was typical that, after working on problematic issue, it was followed
with a break from being talked about in therapy, only to be returned later on
in therapy.
The therapist was an experienced integrative psychotherapist, where
therapy was conducted on a weekly basis for a year. The case material was
gathered in the Psychotherapy teaching and research center at University of

89
Jyväskylä. It consists of 32 sessions that were videotaped, and transcripts
made based on these videotapes.
Assimilation of Problematic Experiences Sequence (APES) and Assimilation
Analysis
The APES (Stiles & Angus, 2001; Stiles et al., 1991) summarizes
psychotherapeutic changes in a patient’s relation to a particular problematic
experience in the following sequence of eight stages:
0 Warded o,
1 Unwanted thoughts/active avoidance,
2 Vague awareness/emergence,
3 Problem statement/clarication,
4 Insight/Understanding,
5 Application/Working through,
6 Resourcefulness/problem solution,
7 Integration/mastery.
The sequence is considered as a continuum, and intermediate stages (e.g.,
1.4, 3.6) are possible. Researchers can use these stages as a way to describe
their estimates of the degree to which the problematic experience has been
assimilated. The APES has sometimes been used as a formal rating scale.
However, we did not do formal APES ratings in this study, but instead used
it as a way to be precise about our own interpretations of passages in the text.
Assimilation analysis (Stiles & Angus, 2001) is a procedure for
tracking the idiosyncratic developmental path of an individual client’s change
processes. It is a exible procedure that generally follows the following four
steps:
1 Familiarization. Recordings, transcripts, and other case material are
intensively reviewed.
2 Theme identication. Based on the acquired familiarity and notes,
the investigators identify themes or problems that seemed salient and
therapeutically important. It is often easiest to identify a problem after it has
been clearly formulated (APES stage 3) or when insight is achieved (APES
stage 4; Leiman & Stiles, 2001). Once the problem is clearly identied, it is
often possible to recognize incomplete or distorted manifestations at lower
APES stages in earlier sessions.

90
3 Extraction of theme-related material. Session material relevant to the focal
theme are excerpted and examined in sequence to highlight the changes or
lack of changes.
4 Interpretation. Changes in the expression of the focal problem are described
and interpreted in theoretical terms, such as by applying the APES.
Dialogical Sequence analysis
DSA is a microanalytical tool to study utterances (Leiman, 2006, 2012).
The conceptual tools of DSA are used to denote and formulate internalized
action patterns and reciprocal patterns mediated through utterances (Leiman,
2012; Tikkanen, 2015). The theoretical concepts of DSA are based on
Bakhtin’s theory of utterance (Bakhtin, 1981, 1984), Vygotsky’s theory of
sign-mediated activity (Vygotsky, 1978) and the basic concepts of cognitive
analytic psychotherapy (Leiman, 1992).
The basic unit of analysis in DSA is the semantic position. Aligning
with the activity theory all psychic activity, utterances are specic type of
actions and are object directed. The relationship between subject and the
object is reciprocal, and it determines the subject’s relationship to the object.
As a unit of analysis a semantic position can be summarised as the referent
and the relationship to the referent. The semantic position corresponds with
the analytic unit of the assimilation model, the subject’s attitude to the object
(Stiles et al., 1992). Both require that the object is spelled out in the analysis
and assume that the subject has a specic relation to the object.
In this study, the following working denition of the unit of analysis
and semantic position is used: shame is the emotion word that describes
the subject’s relationship to the referent. From a research perspective this
is problematic, because if shame is indirectly expressed there might not
be ‘emotion word’ to be seen from the utterance. The problematic shame
experience shows itself through the avoidance of it.
The aim of analysis is to identify these recurring patterns of positioning
with regard to a varying range of objects. Utterances are also actions and the
objects of actions are called ‘referents’ in DSA. Utterances are a special type
of action in the sense that it has simultaneously two referents – the object
of action and the addressee. When speaking I am at the same time speaking
about something and addressing my talking to someone, where the real or

91
expected answer from the other organises my expression and the choice of
referents (for example if I don’t trust the other I might not speak clearly about
what is bothering me but select other mildly bothering things to talk about
instead). These aect the dynamics of the semantic position: who one speaks
to aects what can be spoken about and vice versa. By dening the quality of
semantic position we can articulate how the subject relates to the referent and
the addressee of his/her utterance. In research, DSA is always conducted in
data-session groups. (see Kivikkokangas & Leiman, 2019; Tikkanen, 2015)
The procedure
(A) Following the DSA procedure, the very rst session was analysed to
form a baseline. The initial case formulation began by constructing a
hypothesis of salient semantic positions in a data session of the rst
episode.
(B) Following the assimilation analysis procedure, the rst author read
the transcripts from the whole therapy and watched from a video
the relevant sequences used in this study. This was done to create
a general understanding of the whole of therapy and how shame
might manifest during the sequence of sessions.
(C) The problematic shame experience was dened using episodes in
which it was clearly formulated. For this, we relied in part on earlier
research on the Hanna case (Hartikainen, 2013; Keto, 2010), in which
sessions 7-9 were shown to manifest ruptures in the therapeutic
relationship associated with shame (Hartikainen, 2013).
(D) Episodes during sessions 7-9 that manifested shame experiences
were selected for intensive analysis. This process was iterative
in the sense that new episodes began to appear relevant and were
included as the analysis proceeded.
(E) We described how shame manifested in the sessions 7-9 and how
Hanna’s relationship toward the problematic shame experience
developed from APES stage 1 to ultimately reaching APES stage 5-6.
(F) The completion of the analysis of sessions 7 -9 enabled a return
to the data from lower assimilation stages in earlier sessions with
this enriched understanding of the problematic experience and its
manifestations (Leiman & Stiles, 2001)

92
4. Results
The start of therapy: being seen as the problematic experience
The rst clue of Hanna’s problematic experience and her relation
to it could be seen during the very rst moments of the initial meeting, as
Hanna completed a form related to the study. The therapy was conducted and
transcribed in Finnish; selected excerpts have been translated into English for
this paper by the rst author.
Vignette 1 (session 1, lines 31 – 40, APES 1-2)
31 Hanna: For me it has always been a place of horror to be photographed
or lmed, but here it is not noticed () that it can be forgotten () but I don’t in
the rst place if I () or so or stien like a
32 THERAPIST: [mm] [mm]
33 HANNA: log although if () but I can prevent myself from thinking about it
because it doesn’t show in this room
34 THERAPIST: yes
35 HANNA: here is my () the date is () [I can’t remember
36 THERAPIST: [today is the 28th]
37 THERAPIST: but its the kind of thing that one probably gets used to that
it is then not () remember that ()
38 HANNA: when you don’t have to see it by yourself
39 THERAPIST: yes
40 HANNA: that’s the way it goes () yes
In the rst moments of the initial meeting before the formal beginning
of therapy Hanna expressed her problematic experience: ’for me it has always
been a place of horror to be photographed’ (Vignette 1, line 31). This vividly
conveyed what being seen felt like to Hanna. She continued by explaining
how she coped with being seen: ’but here you don’t notice it () that you can
forget about it () but I don’t in the rst place if I () or if I or stien like
a log’ (Vignette 1, lines 31-32). It was not possible to tell from this early
utterance how this semantic position toward being seen, her ‘’horror place’
had developed or to understand the referential network this was linked to
for Hanna. The semantic position showed a problematic relationship to a
referent, the horror of being lmed, and her way of trying to shelter herself

93
from her horror: ‘I can prevent myself from about it because it doesn’t show
in this room.’(Vignette 1, line 34) The ‘it’ referred to the camera behind one-
way mirror directed at her, but that she could not see. At this point, Hanna’s
problematic experience was apparently at APES stage 1, as Hanna actively
avoided and preferred to not think about it.
Initially, the integrative psychotherapist overlooked these clues and
didn’t follow where these associations might have led to. The words that
Hanna used to describe her experience of being lmed, ‘I stien like a
log,’ expressed a feeling of paralysis, a lack of movement. The therapist’s
comforting formulations aimed at easing the emotional situation of the
patient ‘but it’s the kind of thing that one here probably will get used to that
one doesn’t than () remember that’ (Vignette 1, line 37) seemed aimed at
bypassing the problematic experience. Hanna responded to sweeping away
the possible problematic nature of being lmed at by saying ‘like when one
doesn’t need to see them’ (Vignette 1, line 38). This was armed by the
therapist by ‘so (it is)’ (Vignette 1, line 39).
Hanna returned to the problematic nature of being seen a few minutes later:
Vignette 2 (session 1, lines 84 – 96, APES 3)
84 HANNA: a well () especially for me it’s so hard to express any feelings
that go on in my mind that they just don’t ()
85 they don’t show although of course they exist I don’t get angry then if it
was the time to raise
86 one’s voice or confront something uhm () well I’ve not been crying a lot
but just
87 that kind of () and like the kind of joyfulness that’s gone I can’t like for
example anymore
88 laugh at all or the want is lost () but somehow I can’t (example removed
lines 89-91)
92 THERAPIST: mm
93 HANNA: and if I’m anger of course sometimes the kind of feeling that one
should say something about then I just feel like
94 the kind big pressure inside that tries to pursuit out it’s the kind of anxious
feeling I don’t
95 know if it’s like fear mainly or () or kind of anxiety that I don’t say anything I
96 just smile and be like yes everything is very good

94
Hanna’s central problem of being seen was here manifested in social
situations: ‘it’s hard for me to express any feelings that go on in my mind
that they don’t they just () they just don’t show although they of course exist’
(Vignette 2, line 84). The intonations, tones and gestures that accompany our
utterances show, what kind of emotional relationship Hanna has toward what
she is talking about (the referential object) position her reciprocally towards
what is spoken about (the referential object). On the manifest level the report-
like way of telling, the abundance and monotonic tone is something that
easily escapes from attention, something Hartikainen (2013) has also paid
attention earlier in Hanna’s way of talking. Hanna talks about the diculty of
expressing herself, and the way she speaks of it contains the same distancing
shelter. When we speak using the tones that we use it tells us how we feel about
something: report-like way of describing prevents those tones from evolving
and thus hides the speaker’s relationship toward the referential objects. Hanna
poignantly described how her relationship toward her problematic experience
was caught in the dialectical tension between being seen/exposed and not
showing/being exposed: ‘they just don’t show although they of course exist’
(Vignette 2, lines 84-85). Hanna hid herself by leaving her own attitude and
feelings toward referential objects unexposed; this felt for her as ‘pressure’.
Not showing her relationship toward referential objects here was exactly her
relationship toward the problematic referential object.
Hanna linked her diculties in expressing emotions with her inhibitions
in expressing aggression. This is an example of how the stage of assimilation
is connected to the referential object. While talking about the invisibility of
her feeling, Hanna seems to refer to the problematic nature of her actions ‘and
well () especially for me it’s like really hard to express any emotions that go
on in my mind that they don’t () don’t show although they of course exist’
(Vignette 2, lines 84-85). This seems to indicate the problem moving between
APES stages 2 and 3. Although Hanna didn’t disclose to what referential
object her hiding of feelings referred to (APES 4), she described her actions
in a reective way (Vignette 2, lines 94-96); that is, her description involved
self-observation concerning the relationship between her emotions and
actions: ‘the kind big pressure inside that tries to pursuit out, it’s the kind of
anxious feeling. I don’t know if it’s like fear mainly or () or kind of anxiety
that I don’t say anything. I just smile and be like yes everything is very good.

95
In summary, these vignettes from the rst meeting suggest the following
formulation of Hanna’s problematic experience: Being seen and being exposed
in front of another was very threatening for Hanna, leading her to lose her
sense of aliveness and experience a sort of paralysis (‘stien like a log’). She
avoided this threatening relational positioning by denying or forgetting how
she would be visible in the eyes of the other. Hanna had diculty trusting
others or accepting reciprocity, as was shown by her diculty in expressing
her own opinions or showing how she felt. As she put it, ‘It’s hard for me
to express any feelings; they don’t show although they of course exist’. For
Hanna, the diculty of expressing her opinion was related to her problematic
relationship toward aggression; she felt that she avoided conict in interaction
in maladaptive way, not standing up for herself in situations where actions
were needed to maintain her boundaries and dignity. Other people in general
seemed frightening and anxiety provoking to Hanna, whose main way of
dealing with these problematic situations (how to be in contact with another,
how to keep one’s own boundaries) was to be silent or try to please the other,
and in that way maintain the connection to the other and avoid conict by
being submissive.
The story of Hanna’s shame - sessions 7-9
In the next section, using the sessions 7-9, we will show how Hanna’s
shame was manifested in psychotherapy and how her relationship toward
the shame-evoking referent was successfully transformed. We have divided
Hanna’s shame story into three sections: ‘The horror of being exposed’
(session 7), ‘Going to middle school’ (session 8) and ‘Hanna’s shame becomes
visible’ (session 9).
The horror of being exposed (session 7)
The general theme of the session 7 was Hanna’s horror of being exposed.
The referential object of her horror was her father’s behavior. Hanna began
the session by talking about a couple who had visited their home the previous
autumn. The man had been part of Hanna’s father’s drinking gang. Hanna’s
usual strategy of avoidance (APES 1) failed her here, and she revealed that
her father had sexually abused her when she was a young girl (Vignette 3).
The actions of the other (her father’s drinking companion) addressed Hanna’s

96
problematic experience at APES stage 1 and the painful material emerged
(APES 2).
Vignette 3 (session 7, lines 102 – 112, APES 2)
102: HANNA: I was furious at Denis just about like yes how great it is that
() you know what this great man of yours (Hanna’s father and the reference
to sexual abuse)
103 did to me when I was well () the kind of young girl () and I didn’t say like
anything else
104 he () he just went () well went quiet () and that was it () or like () didn’t
know anymore
105 even that () what what he would say then it stopped the whole thing ()
there and () then of course when I had ()
106 said it then it was like totally terrible that now I have said it like that (and then)
107 THERAPIST: (how was it so) terrible/
108 HANNA: well that’s the kind of thing one doesn’t go out and say out loud
rst of all () one needs to be awfully precise () there are are things
109 from which one should () better be quiet about () to think at least to whom
one says and to whom not () not the kind of ()
110 man who is like the ultimate ()gossipwatch () or like and then it was so
terrible thing
111 overall that I said out loud or put into words that () that bad thing that ()
it shouldn’t be like ()
112 one should be silent about it () and
Hanna began by speaking about the episode in rst person (‘I was
furious’), but after the therapist’s question, her answer was in the voice of the
generalized other – speaking in a passive form, setting the prohibition (lines
108-109), and simultaneously distancing herself. This instantly led to anxiety
about the ill will of the villagers, when the secret about the sexual abuse was
revealed. However, Hanna did not understand the source her anxiety. That
is, Hanna was not consciously aware of the referential object to which the
anxiety referred to, although she felt the anxiety, and her position became
visible in her reaction.

97
Vignette 4 (session 7, lines 137 – 151, APES 1-2)
137 HANNA: if Denis (fathers friend) went to talk to somebody, if he told ()
in the villages where he moves around,
138 where everyone knew dad () and, like, would tell () what I have said, it
would
139 only turn against me, (and like)
140 THERAPIST: (like how) do you think?
141 HANNA: Uhm, like that () hmm () that in the end it’s me who is like the
real cunt,
142 that I dear to derogate my dad’s reputation. Dad has rested in grave for
ve years already ()
143 and I begin to speak about such matters () Uhm () suddenly that () it went
() it would be () my evil deed () hmm I know well what kind of folks there
live indeed.
The salient referential objects are ‘father’s friend’ and ‘village people’.
Hanna describes, using quite laden expressions, their position to her, if she
disclosed her father’s behavior toward family members. It is noticeable that
the composition is self-referential. Hanna perceives herself through others’
eyes: ‘It’s me who is like the real cunt’ and ‘my evil deed’. The broader,
social network of meanings behind such expressions involve father being
an idealized war hero in the village. Interventions made by the therapist to
encourage reection remained unfruitful (Vignette 4, line 139; 144; 147), as
Hanna described her way to escape the overwhelming anxiety – staying away.
Vignette 5 (session 7, lines 198-211, APES 1)
198 THERAPIST: [are you in contact] with them (removed lines 199-203)
204 HANNA: well not really that much () in that way that () that I don’t for
example like visit
205 anyone in that way or they don’t visit us but these people that you bump
into ()
206 always, these old persons of the village
207 THERAPIST: then it is in a way
208 also something like the sense that () hmm () that you can’t for sure know
that they would now say to you

98
209 like that but you in a sense imagine that they think like that
210 HANNA: mm () in some way by knowing the nature of the kind of small
countryside village ()
‘Going to middle school’ (session 8)
In session 8 Hanna’s horror of being seen occurred within the therapeutic
interaction. This proceeded in three stages. First Hanna described (Vignette 6
and vignette 7) how the understanding meeting with her cousin transformed
her relationship toward the shame-evoking referent and enabled her to go to
middle school. (APES 2-3) Secondly, while talking about the cousin, Hanna’s
bodily state shifted noticeably. The therapist pointed to this, but Hanna wasn’t
able to use the intervention and avoided the topic. (Vignette 8, APES 1-2) The
horror of being seen emerged in the here and now interaction, which led to the
third stage: Hanna later linked the ‘mockery of the villagers’ to the ‘snort of
the therapist’ (Vignette, 10, APES 2).
In session 7 Hanna had related in an almost paranoid way to the villagers
but couldn’t consciously grasp what (referential object) this was linked
to (APES 2). In session 8, she described how that problematic experience
became claried in a discussion with the therapist about a childhood talk
with her cousin about going to middle school. Hanna’s formulation ‘I was so
afraid that when dad gets drunk at the church village that I have to bump into
him so’ approaches an APES stage 3 formulation, but still left the feeling of
shame unarticulated. (APES 2.5)
Vignette 6 (session 8, lines 244-253, APES 2-3)
244 HANNA: I well ()
245 I refused to go to middle school or the like from my fourth grade you
should have applied
246 there but I was like totally that I won’t go there and () well no one like
understood
247 at all about it like what the kid is being dicult what has she gotten in
her head an ()
248 needs to be hard-headed () and well no one got the idea that except my
cousin
249 then who in the end got me to go to school just like in the way that he talked

99
250 with me and () because he understood () to ask the right question in a
way that um ()
251 is it about some people who are at the church village () where the school
is and I said like
252 yeah () and that it is about it and () like I was so afraid about that my
father drinks there at the village
253 that I have to bump into him that I () am not going to that school
Hanna described how she tried to solve the threat of shame that was
linked to her father’s behavior by refusing to go to middle school (Vignette
6, APES 2-3). However, she didn’t have a reective stance to her narration
(APES 4). In the previous sessions Hanna related in a suspicious way
to the villagers, but couldn’t reach where that strong relating referred to
(APES 2). Here (Vignette 6, lines 252 – 253) that problematic experience
is claried in the discussion with the cousin about going to middle school.
Hanna’s formulation (Vignette 6, lines 252) about fearing to run into the
drunk father in the village approaches an APES stage 3 formulation but
doesn’t explicitly articulate the feeling of shame relating to this referential
object (APES, 2,5). However, after the encouragement from the cousin, it
became possible for Hanna to recognize her wish to go to school behind her
fear (Vignette 7, APES 2)
Vignette 7 (session 8, lines 254 – 259, APES 2)
254 HANNA: well my cousin just said then that () not even mentioning my
father or any names or like that but
255 there was just this kind of shared understanding created that () yes that
you don’t () need to like care
256 about that there is () like all kinds of stupid people who can say something
nasty and () that
257 way but it’s not like your fault you don’t need to care about all that ()
258 just go to the school and well then I just wanted to go to school () so that
it was so () or like
258 simple () in a way that () if someone had just talked about all the kinds of
things that this () well
259 cousin for example underst- understood me and it

100
The cousin’s encouragement problematized the way Hanna had
previously (Vignette 7) tried to solve in avoiding manner the threat of
revelation of the shame of her dad’s behavior by pointing to a solution ‘if
someone just had talked (to me)’ (Vignette 7, line 258). The problematic
experience was thus at APES stage 2, but it expressed an alternative position
toward her shame in a not yet consciously grasped way. This anticipated the
insights of the session 9.
While she was telling the story of the cousin, Hanna’s bodily state
changed noticeably. Therapist picked this up and referred to it as ‘being
moved’. This comment about ‘being moved’ by the meeting with her
understanding cousin invites instantly the voice of the internal other to the
scene, which invalidates everything. Hanna was not able to express her own
experience freely. She didn’t articulate or didn’t know to what the relation
term ‘being moved’ referred to. This is shown indirectly in her expression ‘(it
felt) good’ by saying something that functioned in the discussion as a way of
ending the exploratory movement and aligning to something that the therapist
has said how it should have felt.
Vignette 8 (session 8, lines 277 - 287, APES 2)
277: THERAPIST: I just felt a moment ago that it was somehow like that you
had been moved when you
278 you told about it but () did you have the kind of feeling
279 HANNA: well maybe what could be the cause then is the cousin was very
moving or like he was like
280 in my childhood the kind of () that it’s moving because he was so () um
() good
281 THERAPIST: I think that what it felt for the little girl always felt good
when somebody talked and somebody who
282 cared and () that you can get some kind of a () or does it produce the kind
of connection
283 to the feelings of the little girl () these experiences where you re () that
you were cared for and ()
284 that somebody understood () sometimes
285 HANNA: well yes, that again in that way () hard I’m trying to think I
don’t () I don’t nd the () thought

101
286 that way () yes the connection
287 THERAPIST: that you didn’t have the kind of feeling then but I interpreted
a bit wrongly it seems
In Vignette 8, Hanna identied with her experience of being worthless.
As she put it, ‘I try hard to think I don’t () I don’t nd it ()’ (Vignette 8, lines
285 – 286). In her sentences she used the rst person without a reective
stance to what she talked about, and describing without a reective stance
signals APES stage 3. In the therapeutic relationship, this was followed by
Hanna’s projective attitude towards a therapist’s ‘snort’, which she understood
as mocking and judging her (Vignette 10. Hanna was able express the content
of this projected attitude toward the ‘snort/laughter’ but was not able to relate
to it reectively (APES 2). We understood this as a repetition of Hanna’s
attitude to the mocking villagers, where the threat of mockery and scorn
evoked the same way of acting toward the projectively described experience.
Hanna controlled the discussion by quickly going forward from this, not able
to reectively stop to explore the ‘snort’ and what kind of referential network
it might be connected to. However, the therapist’s intervention of inviting
Hanna to reect on this the problematical relational situation succeeded, and
she then addressed this issue.
Vignette 10 (session 8, lines 423 – 431, APES 2-3)
423 HANNA: you laughed or it could be seen from the face that you let out
the kind of noise that mainly sounded like laughter (Here Hanna refers to the
therapist’s snort that occurred before this comment)
424 that I didn’t say this thing correctly // I thought //
425 that I need to change this word order or do something to this sentence
426 in that situation you would have thought like that oh god again that
Hanna turns this around
427 against herself //
428 because you had just said before that here I am now
429 blaming myself and that sound just like that //
430 isn’t that person capable at all //
431 of ceasing to blame oneself

102
Hanna rst described ‘the snort’ (Vignette 10, lines 423-424)
unconditionally (‘you laughed’), then as if correcting herself about the
interpretation of the facial expression (‘or it could be seen even from the
face’), and in the end as if it was her tentative interpretation of the therapist’s
expression (‘or you revealed the kind of noise that mainly sounded like
laughing’). This is a crucial moment of change, where Hanna takes initiative
in her own hands in order to deal with the experienced problematic situation
instead of being silent and ashamed, or silenced by the shame. Although
Hanna can take the initiative and describe how the threat of being laughed
aected her expression (‘I thought, I need to change this word order or do
something to this sentence’), she’s unable to gain reective stance toward her
projective attitude ‘(Vignette 10, lines 447-453) regarding what the therapist
‘really’ thought about her. The therapist pointed out that it might sometimes
be useful to say that she doesn’t understand and not be silent just to please the
therapist. To this Hanna – repeating the problematic situation just described
- responded without actually grasping the idea in the therapist’s formulation
(APES 2; Vignette 11).
Vignette 11 (session 8, lines, 531-536, APES 2)
531 HANNA: this is again in that way hard like how should it be continued
from here like ()
532 that now I need to be careful and () say () if I notice that I’m beginning
to be
533 THERAPIST: did it go dicult
534 A. to be pleasing or () just tell you that I don’t understand you () or like
this but how I’m going to like
535 be pleasing to you from this moment on but I’m telling you now that I
have the kind of intention () and
536 that can be stopped then there
This momentarily rupture in therapeutic relationship was addressed and
worked on, leading to a bad memory from Hanna’s previous therapy where she
felt laughed at and mocked. Although we don’t know what ‘really happened’,
as she described it, that rupture remained hidden from the joint observation and
work. The previous therapists’ laughing had evoked ‘shame.’ This sort of thing

103
had happened before, and Hanna was trying to avoid it happening again in this
therapy. However, Hanna hadn’t been able to build a reective stance toward
threat of shame. When events made her feel worthless, she either tried to avoid
the shame or was driven to projective ways of relating to the other (APES 2).
Vignette 12 (session 8, lines 544- 552, APES 2)
544 HANNA: He like laughed at that kind of spot that don’t
545 for god’s sake laugh like that () and in that spot () that somehow started,
me being more
546 being careful after it, that was () unpleasant experience. I thought that in
no circumstance
547 I would want to repeat that here with you () // or that
548 I would say something like that the therapist couldn’t stand it () //
549 or you to be angry at me, it (the last therapists actions) was terribly
550 shocking I didn’t expect that it would have happened like that and from
it one became
551 a bit scared or that one tries you know even more now when one is in
therapy that there wouldn’t be created
552 that kind of () situation
’Hanna’s shame becomes visible’ (Session 9)
In session 9 Hanna was able to form a new active relationship towards to
the shame-evoking referent. She was able to integrate it in a way that generated
a new understanding to her own life history. Changes in assimilation stages
take place in three stages: 1.) reaching a new understanding of her problematic
experience (APES 4; Vignettes 13-14), 2.), working through this new
understanding (APES 5; Vignettes 15-16), which eventually led to 3.), a partial
solution of the problematic shame experience (APES 6; Vignettes 17-18).
In the beginning of the session 9 Hanna returned to the feeling of
‘being moved’ by the meeting with her cousin. Apparently, she had thought
about this on her own between sessions. She spoke in rst person yet did not
identify with the feeling of being worthless (Vignette 13, lines 15-16). The
dicult feeling, which Hanna couldn’t understand, demanded to be thought
about (Vignette 13, lines 15-16). This was an interesting illustration of how a

104
warded-o problematic experience (Vignette 13, line 11, APES 0), signaled
by a dicult feeling, can become a topic of self-observation. The relationship
to the referent acts as if it is a clue to the referential object, which is not yet
articulated clearly. (Vignette 13, lines 12-13, APES 2-3)
Vignette 13 (session 9, lines 11-16, APES 2-3)
11 HANNA: There when we talked about my cousin who made me to go to
school () well eh and about
12 speaking about it suddenly in some way () it wasn’t instantly at all pleasant,
but it was really totally
13 terrible () it was really unpleasant, like some kind of ugly black troll
14 THERAPIST: really
15 HANNA: somewhere there at the edge, I didn’t know, like what it is () and
from it I just thought
16 like two days that why did I got the feeling like that (and well)
At rst it was dicult for Hanna to grasp what the ‘terrible feeling’
referred to. First, she linked it to the disappointment that the cousin hadn’t
asked about previous bullying experiences and had just said to go to school.
Then, Hanna responded to the therapist’s clarifying question focusing on
the feeling the cousin evoked: ‘but behind it there was like the kind of ()
like anxiety () or like sma small horror.’ (The small horror referring here
to Hanna’s hesitations uttering the word ‘sma small’) Hanna was then able
to grasp something (APES 3-4) that she hadn’t been in touch with in the
previous session.
Vignette 14 (session 9, lines 73-76, 91-93, 96-97, APES 3-4)
73 HANNA: the conversation wasn’t nice at all and I remember that I was
sullen a lot and I was very
74 monosyllabic but then afterwards really relieved and then I got to
75 school //
91 I would have stuck to what I wanted after saying many times that I am not
leaving, but //
92 he somehow like understood my secret this cousin //
96 somehow like I was so pissed at 11 years old that I was like revealed and
that he like reads me like an

105
97 open book I don’t remember () but something made me be very sullen at
that phase when we talked
Then Hanna gave examples to explain the referential network to which
the shame evoking-memories were linked. She also explained how she had
tried to survive with them, for example, when her father came drunk to her
school bus or when ‘the teacher made my dad the eye eyesore like the whole
class ran () to the window to stare.’ Hanna described her feelings in this
instance:
Vignette 15 (session 9, lines 163-172, 220- 238, APES 4-5)
163 HANNA: I was like indignant about it and //
164 and I somehow just thought that I am not going there () //
165 and I just stayed () sitting there and the teacher () talked there
166 more like where she has seen the man before and the like () and at that
time it was beginning to be () terribly () clear that it is my father () I became
terribly () small and
168 puny it was like so self-evident thing that I couldn’t stir a bit from my seat
that I like
169 now () I’m like disappearing to nothing hopefully () and well () no one
said a thing
170 like knowing the man or the like but then one boy came who was from my
neighborhood () to me and //
172 laughed so much and said it’s your father //
220: HANNA: had to go somehow, had to be not thinking //
223 to raise and arrange a kind of posture to one’s face that is thought to be
appropriate
224 uninvolved calm willingly like without a- any expression and it is about
that one looks to no direction //
226 just to place one to sitting and starting to look at the bench //
228 I don’t know what others thought but for me it was terribly
229 shameful. I needed to develop a kind of shell somehow to keep face
Hanna’s way of trying to deal with her shame was similar to her strategy
in ‘going to middle school’: being silent and avoiding the referent that evoked

106
shame (‘I refuse to go’). By working between the sessions on her own, she
gained a new understanding of the history of her shame experience and how
her ways of dealing with it had formed. The relation to her father’s behavior
(the referential object) wouldn’t inevitably have had to develop into shame
(‘one could have also raised in another manner to relate to this’; Vignette 16,
lines 300-302). Being exposed or becoming visible was the central threat to
be avoided (Vignette 16, line 302). Here Hanna began to achieve a sense of
agency; which is shown in her active and forward-looking stance toward her
problematic experiences (Vignettes 16 – 19).
Vignette 16 (session 9 lines 291-302, APES 5)
291 HANNA: that it was mom who so terribly communicated to me that
292 really could raise up in some other way of relating to the thing //
293 so this is for us such a terrible shame, shame that your father is like that
and () and () all () what then could dad now
297 do, mom painted all kinds of pictures that () If dad does this and that if happens
298 that kind and this kind then () we are plunged into feeling ashamed of
him. That frightens so much that () or ()
299 like sure it catches quick. I was probably well for example when I started
300 school then I was steeped in to the kind of () shame and fear that I was
the kind of terrible thing
301 on you like how to keep this () hidden and avoid and () lie and do whatever
in such way that this terrible shame wouldn’t be revealed
Working on the dierent sides of the problematic experience continued,
when the therapist returned to the ‘therapists snort’ and the threat of shame
in the relational context with a signicant other. Afterwards it was possible
for Hanna to describe and reect upon the situation in a less projective way,
which had not been possible in the previous session (Vignettes 9 – 11).
Hanna described how she didn’t feel the ‘snort’ in that situation had been
unkind or mocking laughter in the sense she had felt the previous therapist’s
behavior. Hanna talks about her experience from another stance than in the
previous session, where during the problematic experience her attitude to
the therapist was projective without reection (‘You laughed!’, Vignette 9).
Here (Vignette 16) Hanna places the not-understanding and mockery to the

107
previous therapist. In short, Hanna denies having felt the current therapists
snort as potential mockery – although the data shows, that she did (Vignette
9) – and in this way protects the image of the present therapist (from this kind
of behavior that the previous therapist was capable of).
Vignette 17 (session 9, lines APES 5)
338 HANNA: shame that was what came out of it () I’m stupid () I am such a
339 stupid strenuous and unbearable goose that even a therapist can’t stand
me, now he got already
340 angry //
358 even he of course didn’t probably think like in that fashion but //
360 but I take it out on myself because I am
362 the kind of person I am, and of course I got that (the way of thinking of
herself as ‘stupid strenuous and unbearable goose’) from shame
Hanna next revealed aspects of her mother that had previously been
unspoken. Indirectly Hanna problematized the way she had developed. She
seemed to be working toward an understanding of her shame, where the
shame about her dad’s behavior hid something more. Hanna couldn’t talk to
her mother because she feared or expected her mother’s anger or mockery
(Vignette 18, lines 484 – 485). Hanna described her fear of becoming like her
mother, concerned with how she might prevent this.
Vignette 18 (session 9, lines 482-490, APES 5)
282: HANNA: usually they say that daughters tend to become like their
mother or one notices in oneself
483 something like that but I don’t notice like anything good () but that I
would not be becoming like
484 the kind of who () bursts explosively suddenly get angry over something
() or that is like so
485 cold like mom knew how to be the kind of ice cellar () where she threw
mockery sticks () //
486 what if I don’t notice that I change //
487 I don’t know why mom was a bitter human she was () tired and
488 sick and bitter () if the same happens to me () here one must
489 somehow put on a ght on if it could somehow be prevented and I don’t know ()

108
Hanna’s self-observations about the previous session (session 8) thus
led to a new self-understanding. This enabled her to move from the ‘dark
cloud, mirthless and stuck’ toward a more ‘liberated, alive and talking with
others kind of being and doing.’
Vignette 19 (session 9, lines 512-520, APES 5-6)
512 HANNA: I can do the kind of very small things that have been to me like
513 impossible because I’ve been afraid of so much () what consequences are
there if one
514 goes and does something //
515 I feel myself at least a bit more courageous () that I dare to say about
the kind of things that I previously wouldn’t in anyway () open my mouth and
516 then try it a bit how it () feels like to dare () really () to speak where one
speaks and
517 then to notice that it wasn’t so
518 bad that I can do it and () I did it anyway () that there came now shame
519 or well () embarrassment () no one (no) said that stupid, well when I have
noticed that there’s actually no () one saying things like that
520 then I am going to () continue it (the daring to say the kind of things she
wouldn’t previously say) and try more things that come with that (way of
being active)
In summary, during session 9, Hanna rst described how her developed
self-understanding of her ’terrible feeling’ was linked to her meeting with an
understanding cousin (Vignette 13). Here Hanna’s assimilation of the shame
evoking problematic experience moved from APES stage 2 to 3 (Vignette
13: Hanna didn’t want to go to school but was not aware of how her ‘terrible
feeling’ was linked to the meeting with the understanding cousin). The work
proceeded towards assimilation stage 4 insight (Vignette 14: Hanna came to
understand that the terrible feeling was linked to the revealing of the object of
her shame to the cousin, triggered specically by his understanding of why and
what Hanna avoided by not going to school). Enabled by this understanding,
Hanna next claried her understanding of how the behavior of her dad had
developed into what she called ‘shame’.
Next, Hanna gradually broke the silence around her story of shame.
Through therapeutic work Hanna addressed the previously unspoken role of

109
her mother in generating her shame (Vignette 16-18; APES stages 4 to 5).
At the end of session 9 Hanna described the change she felt herself about
the problematic experience (Vignette 19): the shame had – at least partially
– been integrated into her self-experience, accompanied by a new sense of
agency and even laughter in daily life (APES 5-6).
5. Discussion
Our broad aim was to show how shame manifests and changes in
psychotherapy. This was done using APES and DSA in Hanna’s intensively
studied single case. The more specic research task was to show how the
problematic shame experience manifested in the patient’s utterances, and
how Hanna’s relationship toward a shame-evoking referent developed and
changed during her one-year therapy process.
Shame was central in Hanna’s very rst words, but only later was it
worked on jointly, and only through this did it become understandable
and meaningful. Across the sequence of sessions 7-9 Hanna’s problematic
experience of shame emerged: rst as a clue or hint, and then gradually
assimilated, following a nonlinear trajectory from APES stage 1 to APES
stage 6. For Hanna, this meant a new kind of developing agency toward the
shame that in the beginning held the agency toward her, in her ‘community
of voices’ (Stiles, 1999).
Hanna revealed the problematic nature of being seen or exposed in the
rst minutes of the rst meeting. She spoke casually of being lmed as ‘place
of horror’ for her while she was lling out the informed consent form. The
therapist did not pick up on this comment. This expression, which could not
have been understandable to the clinician at the time, loomed large to the
researchers after they had assessed clinical data from the whole period of the
therapy.
For several sessions Hanna said nothing about shame besides her
casual comment revealing her horror of being seen. The relationship between
being seen and the gaze of the other (camera) is reciprocal. This semantic
position (horror of being seen) subsequently appeared in relation to a variety
of referential objects, including when Hanna revealed the secret about the
sexual abuse perpetrated by her dad’s drinking buddy Denis (Vignette 3), or
when Hanna referred to the impossibility of going to middle school (Vignette

110
6-7), or when the cousin understood the secret about the true referent of
Hanna’s shame (Vignette 13-14), or in the narration about the dad who came
drunk to her school bus (Vignette 15). Through therapeutic clarication of
the referential network it became possible to understand how all of these
concerned her shame.
During sessions 7-9 Hanna’s relationship toward the shame evoking
referent(s) changed and developed. At the beginning of session 7, she
described how her impulsively revealing the secret of her sexual abuse
evoked a terried, paranoiac attitude toward others (APES 2). In session 8,
she described how her meeting with the understanding cousin claried how
her father’s behavior was the referent of Hanna’s shame (APES 3). Then the
fear of being ashamed became experientially felt in relation to the therapist’s
snort/laughter, where Hanna took the initiative to speak about it. In session
9, after working through this problematic experience in the therapeutic
relationship, Hanna was able to assimilate a new kind of understanding of the
‘terrible feeling’ linked to meeting with the cousin (APES 4). Subsequently,
Hanna was able to work through and integrate her shame experience as part of
herself. She then felt at more liberty to express herself. Working through the
new understanding contributed a new perspective on her relationship toward
her father’s behavior, which could have developed in some other direction
than shame. Hanna also noticed how she was identied with her mother’s
shame about Hanna’s father, doubling the intensity of her shame in this way.
The possibility of initiative turning from pre-narrative shame experience
to dialogue with a signicant other
From a clinical point of view four central steps can be identied from
Hanna’s process that enabled the new kind of active agency toward her
problematic shame experience:
1) A relationship to a signicant other, who does not shame, ridicule or
mock. This is aptly condensed in the way Hanna described the most
meaningful moment in her therapy in an interview conducted after
the end of therapy. In the fourth session Hanna had simply casually
mentioned a book she had been reading. The therapist asked what book
it was, and she answered that it was one by Alice Miller called ‘The
tragedy of the gifted child’. The therapist said she knew the book and
asked what was meaningful about it to Hanna. This was the moment

111
Hanna herself identied as the most meaningful change event in her
therapy. The interviewer asked why this was so, and Hanna’s response
is revealing: ‘When I told her about it, the therapist didn’t laugh or
mock me but was interested and asked me what the book was and what
it was about. There and then, I remember, I thought to myself that this
is a person I can trust and rely on. And then I was able to let go in therapy
and talked about all’. It seemed to us that, in Hanna’s mind, she became
able to trust in the experience of being held in the therapist mind and seen
by her in accepting way, which enabled her to decide in those early stages
to ‘let go, trust in therapy and talk about it all’. The availability of the
experience of a helpful other seems to be crucial for change, where
the emergence of such availability seems to go hand in hand with the
evolving self-agency (see Kivikkokangas, Enckell & Leiman, submitted).
2) In addition to her shame experience being met in a new way in a non-
shaming relationship to a signicant other, Hanna’s problematic
shame experience settled also in a new way in her inner dialogue.
This can be seen in Hanna’s typical way of continuing the therapeutic
process on her own between sessions (see also Hartikainen, 2013),
where she didn’t return to her symptom lled reality of binge eating and
anxiety. The problematic shame experience had entered into dialogue
as something that can be thought about and used to begin the narration
of a non-narrated-story. This is an important addition to the psychology
of shame: shame is shame as long as it can’t be verbalized, it can’t
be talked about or be narrated. The verbalization from the beginning
of the therapy about the ’horror of being seen in front of another’ is
the rst step toward reection. As was shown, this proceeded through
the narration of the meeting with the understanding cousin toward the
verbalization of the hidden reason behind her shame (dad’s behavior),
where Hanna gains a new kind of awareness toward her resistance and
the shame linked to the disclosure of this secret to others.
3) A crucial moment of change, or evidence of the change that has already
taken place12, is how Hanna is able to deal with the therapist’s
laughter/snort in the session 8. The therapist’s laughter wasn’t just
a simple laughter (see Kivikkokangas & Leiman, 2019), the analysis
allows us to see how the laughter referred for Hanna to her father’s
12 In our view, this is the same question as is raised with respect to the various ‘meaningful moments

112
mockery and scorn (session 25), the previous therapist’s laughter at
Hanna and her shame about it (Vignette 6), her mothers’ mockery and
scorn (Vignette 10) and her experiences of being put down as unworthy
to do anything in the workplace.
Hanna was able to take initiative in her own hands in order to deal
with the experience rupture instead of being silent and ashamed, or
silenced by the shame. The feeling of being laughed at and mocked by a
signicant other is experientially felt, which is something Hanna broaches
in a straightforward manner ’You laughed’. The change is signicant from
Hanna’s typical way of coping in the beginning of the therapy by ’being silent
and ashamed’ (Vignette 2) or silenced by shame (Vignette 2, 16), wanting to
say out loud but not being able to ’say anything’ than ’everything is good’.
The laughter was for Hanna a dangerous referent that threatened to move
her to a relational position of being again humiliated and ashamed in front
of another. It posed a risk to her trust in and reliance on the therapist, who
wouldn’t laugh or mock but was interested. This trust had in enabled for her to
enter into the therapeutic process. The raised the possibility of shame within
the therapeutic relationship, repeating her problematic relation toward the
referential object posited in our formulation. Taking this new kind of initiative
into one’s own hands is not so forthright, it’s followed by a step back by not
taking seriously the decisiveness of her previous action. The data doesn’t
show, but it might be argued if in this kind of short-term therapy setting it was
crucial for Hanna to keep the image of the therapist as something certain (as
someone who doesn’t shame, laugh or mock me).
4) Through these steps Hanna was able to narrate her shame story in a new
active way, where she understood being identied with her mother’s
shame on her father’s behavior. In addition, she was able to problematize
how her relationship toward her father’s behavior could have developed
in other ways also and not necessarily just shame. Through being able
models’ used to understand powerful moments of psychotherapeutic change (Elliott, 1985; Timulak,
2007; Gonçalves & Ribeiro, 2012). Wahlström (2018, personal communication) condensed the tension
in these models in his father’s metaphor about a stone cutter: An old man hits a rock with a hammer. He
does this many times and hits the rock from every angle. Then, the last hit cuts the rock. The old man
then asked a boy who watched this operation, “which hit cut the rock?” The boy answered: ‘The last
one’. To this the old man replied, ‘No, all the hits cut the rock’. To apply this to Hanna’s story: Did the
change toward her shameful experience happen in those moments in sessions 7 – 9 when she expressed
this or was it just that at that moment the ‘rock shattered’. The problem here is that our position as a
third-party researcher robs us of a position where we could solve the old man’s riddle.

113
to ‘own her own shame story’, which was actually more her mothers’,
Hanna gained a new type of self-agency toward her life. At the end of
the therapy the talk about shame gradually ceased and the focus shifted
toward life, about what kind of forms this new kind of activeness takes,
and the experiences and emotions dierent things evoke in her. She was
more visible toward herself, others and the world – this was no longer
just a threat and horror, but also a joy of being seen and found.
Limitations and Future Directions
In this study the focus was on Hanna’s utterances and how her relationship
toward her shame evoking referents changes and develops. This poses at least
two central limitations, while also showing aim for future research directions
in single case studies. Firstly, by taking Hanna’s utterances as the focus
of study enables us to take her words and viewpoint as the starting point
for analyses. In other words, what Hanna describes her problematic shame
experience as is what we follow in our research. On the other hand, this
research strategy leaves out of focus how and through what kind of actions
of the therapist or interaction this change toward shame was enabled and
facilitated. Whereas this study shows that change toward a shame evoking
referent did happen during these sessions, a path for further studies could be
to use this as a starting point to focus more on ‘curative elements’, through
what kind of interactional processes this observed change was facilitated and
enabled. Secondly, APES and DSA are both qualitative methods of single
case studies. The aim is not to collect more single case studies that would
enable us to see ‘whether the pattern obtained here is a typical one or specic
to this case’ (Goncalves et al., 2013). The subject can’t be abstracted from the
equation. The aim in this type of research is not to list the semantic positions
typical in shame experiences and how these are changed through some
generalizable pattern (see Kivikkokangas & Leiman, 2019).
On the contrary, Hanna’s story shows how and through what way her
shame had evolved as her shame (and how she tried to cope with it). This
can’t be abstracted from the idiosyncratic developmental history of the subject
(we can’t leave the subject out of the equation). Despite the hiding nature of
shame, this research shows how and through what way something as dicult
to study as shame is, can enter into the sphere of empirical study. Using DSA

114
and APES integratively seems a promising microanalytical way to show and
track the developmental process and change of manifestations of shame in
psychotherapy. Although these ndings on the development and change of
shame from Hanna’s single case study can’t be generalized, they can be used
in theory building way about the subject of study, namely the manifestation
and development of shame through therapeutic process (see Tikkanen, 2015).
By taking Hanna’s utterance as the starting point for empirical study, she was
also returned as the subject of her problematic shame experience at the level
of the research.
REFERENCES
CARO GABALDA, I., & STILES, W. B. (2013). Irregular assimilation
progress: Setbacks in the context of Linguistic Therapy of Evaluation.
Psychotherapy Research, 23:35-53.
FREUD, S. (1912). Recommendations to physicians practicing psycho-
analysis. SE XII. Hogarth Press, London, pp. 109 – 120.
GONÇALVES, M., CARO GABALDA, I., RIBEIRO, A., PINHEIRO,
P., BORGES, R., SOUSA, I. & STILES, W. (2013). How collaboration in
therapy becomes therapeutic: The therapeutic collaboration coding system,
Psychother Res, 24:442-455.
HARTIKAINEN, K. (2013). Changes in interaction – a case study
[Vuorovaikutuksen muutokset yksilöpsykoterapia prosessissa]. Licenciate
thesis. Jyväskylän yliopisto, psykologian laitos.
IKONEN, P., and RECKHARDT, E. (1994). Thanatos, häpeä ja muita
tutkielmia [Thanatos, shame and other psychoanalytic studies]. Helsinki:
Nuorisopsykoterapiasäätiö.
KETO, R. (2010). Emotion regulation in the psychotherapy of
a traumatized woman. [Tunteiden käsittely traumatisoituneen naisen
psykoterapiassa]. Licenciate thesis. University of Jyväskylä.
KIVIKKOKANGAS, S. and LEIMAN, M. (2019). Dialogical sequence
analysis as a method in theory based single-case studies in psychoanalysis.
Scand psychoanal rev, 2:110-118.

115
KIVIKKOKANGAS, S., ENCKELL, H. & LEIMAN, M. (submitted)
Self-observation as a precondition for the development of self-analytic
capacity.
LEIMAN, M. (1992). The concept of sign in the work of Vygotsky,
Winnicott and Bakhtin: further integration of object relations theory and
activity theory. Br J Med Psychol, 65 (3):209-221.
LEIMAN, M. (2006). What does the rst exchange tell? Dialogical
sequence analysis and assimilation in very brief therapy. Psychother Res,
16(4):408-421.
LEIMAN, M. (2012). Dialogical Sequence Analysis as a method to
study psychotherapeutic discourse. IJDS, 6(1):123-147.
LEWIS, H.B. (1971). Shame and guilt in neurosis. International
Universities, New York.
SIEGEL, D. (2015). The Developing mind. Guilford Press, New York.
STILES, W. B., and ANGUS, L. (2001). Qualitative research on clients’
assimilation of problematic experiences in psychotherapy. In J. Frommer
& D. L. Rennie (Eds), Qualitative psychotherapy research: Methods and
methodology (pp. 112-127). Lengerich: Pabst Science Publishers. Also
published in Psychol Beitr, 43:570-585.
STILES, W. B., ELLIOTT, R., LLEWELYN, S. P., FIRTH-COZENS,
J. A., MARGISON, F. R., SHAPIRO, D. A., & HARDY, G. (1990).
Assimilation of problematic experiences by clients in psychotherapy.
Psychotherapy, 27(3):411-430.
STILES, W. B., MORRISON, L. A., HAW, S. K., HARPER, H.,
SHAPIRO, D. A., & FIRTH-COZENS, J. A. (1991). Longitudinal study of
assimilation in exploratory psychotherapy. Psychotherapy, 28(2):195-206.
STILES, W.B. (1999). Signs and voices in Psychotherapy. Psychother
res, 9(1):1-21.
STILES, W. B., CARO GABALDA, I., & RIBEIRO, E. (2016).
Exceeding the therapeutic zone of proximal development as a clinical error.
Psychother, 53:268-272.

116
TIKKANEN, S. (2015). Development of an empathic stance - dialogical
sequence analysis (DSA) of a single case during clinical neurological
assessment procedure. Publications of the University of Eastern Finland
Dissertations in Education, Humanities, and Theology No 68.
TÄHKÄ, R. (2010). Illusion and reality in the psychoanalytic
relationship. Scand Psychoanal Rev, 23(1):65-88.
VYGOTSKY, L.S. (1978). Mind in Society. The Development of Higher
Psychological Processes. Harvard University Press, Cambridge, MA.
WURMSER, L. (1981). The mask of shame. Johns Hopkins University
Press, Baltimore.