W.R. Bion, a British psychoanalyst who worked with psychotic and schizophrenic patients, identified a difficult transition point in their treatment. As psychotic process gradually gave way to the reality principle — that is, as his clients became more sane — they would have to confront the pain of how ill they had been before. This involved facing guilt for the hurt inflicted upon other people around them and shame for the destructive ways they had behaved. Sometimes the guilt and shame were so unbearable that his clients would retreat into psychosis.
I’ve encountered a similar challenge in my long-term work with borderline clients. There comes a time when they realize how ill they’ve been and sometimes the shame they feel is unbearable. They will retreat for a time to borderline ways of relating, where relationships and self-image are highly unstable, shifting between ideals and devaluation. It takes many months and even years before they can learn to bear the shame for the person they used to be; only then can they move on and continue growing. I actually think that anyone with a serious mental illness who spends years in therapy and changes dramatically must deal with the same issue.