The Shame in Mental Illness

DSM5My recent posts got me to thinking about the term mental illness and how stigma-laden it remains to this day. As a society, we’ve come a long way from the bad old days when most people were too ashamed to admit going to a psychiatrist, when families kept those members with obvious psychological problems hidden from view. Back then, a moralistic aura surrounded mental illness, as if having one implied that you (as well as your family) were morally defective and therefore to blame for your emotional difficulties. This view of mental illness still prevails on the religious right — as in the claim that homosexuality is a “lifestyle choice,” for example, and that gays are obviously making the “wrong” one.

In society at large, the easing of stigma has a lot to do with the marketing of psychiatric medication to address “chemical imbalances” over the last few decades. Nowadays, you don’t suffer from mental illness, you have a mood disorder, a result of faulty brain chemistry rather than a moral defect and of course, not your fault. While I strongly object to the widespread overuse of anti-depressants, I do believe that removing the shameful stigma surrounding depression and manic-depressive illness has been a good thing. It’s difficult enough to struggle through depression without feeling you’re a bad person to boot for being “abnormal.”

Furthermore, during the last 50 years, the psychological/behavioral territory defined as “normal” keeps growing broader. Andrew Solomon’s excellent book Far from the Tree tells of many families who embraced a child’s “deviance” (Down’s Syndrome, autism, transgenderism, dwarfism, etc.) rather than hiding it in shame and whose lives were immensely enriched as a result. We live during an “anti-shame zeitgeist,” as I discussed in a recent article for The Atlantic, and this is mostly to the good.

But here is the irony, at least for me: while removing the social stigma attached to their difference is undoubtedly helpful for these individuals, only by confronting the (often unconscious) shame they feel is emotional growth possible. Completely denying the existence of shame promotes defensive identities meant to ward it off. There is no external cause for shame and therefore I do not feel it. From my perspective, the distinction between social shame and core shame has been lost; removing one doesn’t eliminate the other. As you may recall, I define core shame as the felt awareness that your development went terribly awry, departing from what Winnicott referred to as the “blueprint for normality” built into our genes.

Just as the pharmaceutical industry argues that depression results from a chemical imbalance, the transgender argument often focuses on altered brain chemistry to “prove” that transgendered individuals really were “born that way” or that they actually do occupy a body that doesn’t match their psychological gender. Even if this proves to be true, that would imply that nature somehow got things terribly wrong. Statistically speaking, its incidence is several standard deviation units away from the norm. We can enlarge our ideas of what is normal — and I strongly support social tolerance and laws that protect the rights of those who are different — but it won’t eliminate core shame.

When I referred to transgenderism as a mental illness, many people heard it as support for social stigma and for those who seek to persecute this minority group. Instead, I meant to focus on core shame, as I usually do. Let me be clear: I do not think that transgendered individuals ought to feel shame; I’m only saying that, on an unconscious level, they inevitably do. We can and should do all we can to eliminate social stigma, but (in my view) it doesn’t help anyone to collude in a defensive identity that denies core shame. On the other hand, I suppose that shoring up their defenses does help people to keep pain at bay even if it does stand in the way of deeper psychic growth. Maybe for those who can’t afford or access quality treatment, supporting a defensive identity is the best we can do for them.

In a larger sense, something that corresponds to “mental illness” exists, but the term is apparently too laden with social shame. What then are we to call it? The DSM prefers “disorder,” as in Bipolar Disorder vs. manic-depressive illness, but even that word has become tainted, hence the shift from Gender Identity Disorder to Gender Dysphoria. Maybe in the end, we’ll all come to agree with Thomas Szasz that the concept of mental illness is a complete fiction, a label society uses to control people whose behavior deviates from what is acceptable. Maybe everyone will eventually be considered “normal” and we’ll have completely eliminated shame from our lives.

It occurs to me that my views on shame are difficult for many people to grasp because they involve a kind of cognitive dissonance. How can social shame be bad, a force to be resisted, and core shame something to be “embraced” and explored? Because most people equate the feeling of shame with having been shamed by others, they naturally believe that removing those external shaming messages will eliminate shame altogether. If only society would stop shaming people with different mental illnesses, we could erase the shame those individuals feel … right?

If only it were that simple.

P.S. — I have a new article for The Atlantic, about the inevitable narcissistic injury involved in growing older. You can find it here.

Joe is the author and the owner of AfterPsychotherapy.com, one of the leading online mental health resources on the internet. Be sure to connect with him on Google+ and Linkedin.

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40 Responses to The Shame in Mental Illness

  1. Jodi says:

    Hi Dr. Burgo,

    I enjoyed your post and wondered how you weathered the storm after the last post.

    Your quote above “– and I strongly support social tolerance and laws that protect the rights of those who are different –” was the piece that I alluded to in my responses to your last post. I wonder if readers in general understood that people in this profession usually have this stance, if they’re doing it right.

    I liked that you re-articulated above: “Let me be clear: I do not think that transgendered individuals ought to feel shame; I’m only saying that, on an unconscious level, they inevitably do.”

  2. Jane says:

    Your article on middle age and narcissism in The Atlantic really hit home for me! I had not thought it through but I do recognize what you are describing. I am 50, and just this past year I started to do volunteer work on a crisis counseling hotline. My colleagues are mostly 20-somethings who inspire me with their youthful enthusiasm! After reading your article I see how much it feeds me too, as I have many years of experience, even some wisdom perhaps, and they respect me and are interested in what I have to say. I whole heartedly recommend volunteer work as an avenue to pass on knowledge, and boost self-good feelings!

  3. Sheila A says:

    Speaking of mental illness and shame. I have major depression, or whatever the flavour of the month is – used to be clinical depression? Anyway – as one psychiatrist explain to me it develops from a few things- childhood experience, chemical imbalance, current live experience and my personality. Of course I grab on to the last part about my personality. So then I think that it must be my fault, it’s who I am that creates the problem, that somehow I am to blame because I react in the wrong way, I’m somehow week, I’m a freak of some kind and I think to myself “does it mean that if I wasn’t who I am, would I still have depression?” Could all of my suffering have been avoided if I was a different person? So, I do have difficulty wrapping my brain around the idea of it being an illness or a disorder. I blame myself for it.

    • Joseph Burgo says:

      As I was writing, I was thinking about (but chose not to address) the way people who struggle with depression often savage themselves for their difficulties, which can reinforce the whole societal blame thing. Thanks, Sheila.

    • Dolma Beck says:

      Dear Sheila, your brutal honesty about your fragility, warmed my heart.
      Depression could originate from any and all of those causes.
      We have to honour our damaged pasts, but not continue to be enslaved by them.
      But yes, it takes work. I just gotta trust that healing is possible and real.
      Good people, thru therapy / acupuncture/ Meditation/ support groups/ etc. I have gained much help from many people.
      Safe Journey, Sheila

    • Karen says:

      “As I was writing, I was thinking about (but chose not to address) the way people who struggle with depression often savage themselves for their difficulties, which can reinforce the whole societal blame thing. Thanks, Sheila.”

      I feel that many people may savage themselves for their difficulties because that is what they’ve heard from others–that they are some how to blame for their depressive state. The consequence is that one becomes more discerning and less open with others. People who tell others to choose to be happy are missing the point about clinical depression.

      I’ve basically experienced the same as what Sheila writes above, although my psychiatrist focused more on the chemical imbalance rather than the rest. Maybe that was due to the fact that I was already seeing a psychotherapist who referred me to him. She was the one that inquired whether I knew that I could be treated or not. I was open to getting help. Why would anyone ever choose to suffer like that. Unfortunately, I’d met a ton of people who reacted to my honesty about depression by trying to influence me to go the “alternative health” route rather than take prescribed meds. Most offered “unhelpful” help in the form of blame and lack of understanding and compassion. They were the exact opposite of empathetic and encouraging. The ones who were focused on “alternative health” were completely devoid of empathy, although they are good at offering “faux empathy”. Instead they behaved more like combative know-it-alls and as if they were attempting to instill fear and doubt and not only about the pharmaceutical industry but about doctors as well. One woman suggested that doctors don’t want their patients to get well, but to stay sick and make money off of them. It often sounded like fear-mongering and in many ways paranoid like most of the people who I’ve met who are drawn to the “natural health” industry. If I wasn’t convinced and didn’t show agreement then they would behave in very thoughtless, arrogant and condescending ways–much like the personal attacks that you’ve experienced on the last 3 articles.

      Unlike I Sheila I didn’t gravitate to that I must some how be to blame because I don’t react the way other people think that I should, although that was a common enough message that I’ve heard from other people, my family included. People say that they want honesty, but they tend to kick you in the teeth when you offer it. They want agreement and conformity, which is not about honesty. I notice that I’m a much happier person when I’ve severed relationships with blamers and people who try to bully me about to agree with them.

      • Karen says:

        “Unlike I Sheila I didn’t gravitate to that I must some how be to blame because I don’t react the way other people think that I should, although that was a common enough message that I’ve heard from other people, my family included.”

        On second thought–this wasn’t quite accurate. I should have said that I struggled with these thoughts too–that somehow I was to blame and I attribute that to the constant message I heard from others that there was something wrong with me and how I responded or that reacted in the wrong way or even worse that I was somehow to blame for not heeding their stupid unhelpful advice. I heard the judgement that I was “too sensitive” frequently. If you don’t respond the way other people think that you should or the way that they do then they judge you or try to either vilify, criticize or dismiss you in some way. It is always about THEM.

        I was open about how I felt. I would take responsibility for how I felt as well and I was routinely kicked in the teeth for not only being open and honest, but for being expressive PERIOD. These days I’m highly suspicious of people who claim that they want honesty or are “open and honest” about anything. I feel it merely a natural response to all of the duplicity that I’ve encountered.

        Since I found most people inept, lacking in insight and empathy I chose to immerse myself in reading books instead. On that note I found many helpful including Darkness Visible: A Memoir of Madness, by William Styron. His was the first book that I read specifically about severe clinical depression. He aptly conveyed the brutal and debilitating stages of it and how it so often hurls patients into an existential nightmare.

        Dr. Burgo–you don’t have a suggestion page for future topics, etc., if you are open to them. You mentioned above in your response to Sheila that you were thinking about (but chose not to address) the way people who struggle with depression often savage themselves for their difficulties. I wish that you would have or maybe consider it as another article. As always thank you for your insights.

      • Joseph Burgo says:

        Yes, me too. The problem is that it’s hard to sever all relations with such people when you write a public blog on which anyone can comment. The blamers and the bullies will inevitably show up!

  4. YOHAMI says:

    A few ideas / questions

    the claim that homosexuality is a “lifestyle choice”

    Not saying that it is, but so what if it was? what makes something that deviates from the norm more acceptable if the person in question cannot help it or was born that way? I know the answer would be “they cannot change their nature to conform to the norm, so we must accept them how they are”, which coincidentally violates the other commandment “gender is socially constructed” which promotes the idea that nobody, actually, is born as anything.

    So how is being born as a gay man respectable while being born as an heterosexual man questionable?

    And then the “victim” element, I think society doesnt place enough value on people actually making choices, and instead places value on people being helpless, of their own nature, group, society or whatever else. Its as if having will or any say on the matter and making conscious choices is, by itself, disturbing.

    But this of course changes depending on the agenda of whoever is doing the judging.

    • Joseph Burgo says:

      You always raise so many interesting issues, Yohami! It’s a fine line between being unable to change who you are vs. taking responsibility for the choices you make, something I emphasize a lot in my work. You’re right — it’s an easy way out to just say you’re helpless in the face of your difficulties. Relieves you of all responsibility.

      As for the lifestyle issue, making a “bad” choice becomes relevant from the moral perspective, where homosexuality is viewed as evil. You are choosing to sin.

  5. YOHAMI says:

    Congrats on the Atlantic article btw.

  6. Martin says:

    Joe, you claimed that identifying as trans was a defensive identity in itself, and that having such an identity was an indicator of very severe illness. You then made inconsistent but mostly retrograde comments about gender, sex, and sexuality. You now seem to say that transgender people all have a sense that something “terribly wrong” happened in their development, and then collude in the false equation of statistical notions of normal with moral or normative notions of normal (equating what is typical with what ought to be aspired to or is healthful, and conversely, equating what is atypical with what you think must/inevitably experience shame and illness).

    We live in a world that is ruled by the tyranny of “normalness.” Instead of seeing variation and difference just as the are (without moral/healthful attribution), we imbue that statistically normal with moral privilege at the expense of the oppression of folks who become labelled abnormal. This is bad for everyone because it makes the “normals” police (limit) their sense of self and behavior and possibility (in order to maintain their fragile privileged status) and folks who are labelled abnormal bear the brunt of oppression, discrimination, and internalized shame in order for the “normals” to feel more stable in their privilege. I disagree that expanding the boundaries of “normal” is a good thing, because it only displaces shame further down the ladder of “abnormality” or respectability without challenging the binary power hierarchy of normal/abnormal. I would recommend reading Michael Warner’s “The Trouble with Normal” for a more thorough exploration of this topic.

    It is in this multiple and confused meanings of normal that social shame (i think a better term might be stigma) becomes intractably linked with “internal/core” shame, and that I believe these notions support each other (experiencing “core” shame becomes a reason to target social shame and being a target of social shame [regardless how discursive] leads to “core shame). Your comment “I do not think that transgendered individuals ought to feel shame; I’m only saying that, on an unconscious level, they inevitably do,” captures this.

    This kind of comment is the rationale for the switch from GID to gender dysphoria, analogous to the way homosexuality was replaced with ego-dystonic homosexuality. Homosexuality was listed as a mental disorder precisely because the powers at be found it deviant (statistically) and hence immoral (normatively), and anyone who could muster any sense of positive sense of self and be gay in a time of such rigid conformity must be so characterologically disturbed that they should be seen as very ill. After it was replaced with ego-dystonic homosexuality, illness could still be attached to someone if they experienced distress from either stigma (who doesn’t!?) or shame (caused by the stigma that pervaded around homosexuality and continues around transness). However, we have now agreed that ego-dystonic homosexuality is a bogus way to conceptualize psychological distress of inescapable oppression, but I don’t think you see how analogous this is with the pathology of “gender dysphoria.”

    I think you also miss that many transpeople often spend years and decades avoiding their own experience of gender, defensively identifying with gendered norms (for example, if they have male bodies, they engage in competitive sports, pursue careers in adversarial law, military, trades, are constantly dating/trying to date beautiful cis-women,) to prove to themselves that they aren’t trans. It is after they stop that defensive posture that people find comfort and acceptance in what they had experienced of their gender all along. Trans identities are not the defensive identities you think they are, ones that run from them better match your idea of defensive identity.

  7. Greg says:

    One thing that I don’t see explored much is the fact of self stigmatization.

    If even the mentally ill person sees their illness as a deep dark secret, how can they then demand that others not do so?

  8. Cameron says:

    Just wanted to compliment you on the Atlantic article. I thought it was great.

    “For example, many would agree that fathers who walk out on their families, neglect their offspring, and fail to make child support payments should feel ashamed. Shame is the appropriate emotion for those men to feel: if powerful enough, the experience of shame might help them to fulfill their obligations as fathers and members of society. ”

    Technically, isn’t it guilt that these fathers should feel rather than shame?

  9. Evan says:

    Instead of ‘mental illness’ we could talk about what frustrates people, brings misery, inhibits joy. This keeps the qualitative judgement but may go some way to avoiding stigma.

  10. Susan says:

    I have enjoyed and been very interested in your posts about shame. I have anxiety and panic disorder and I absolutely feel shame about it. To me, this seems like something that afflicts the weak and I try to hide it from others, lest they think of me this way. Trying to help myself is a strength (this is what my therapist tells me) and it takes strength for sure, yet it is hard not to feel that panic and anxiety is a weakness in one’s self. I can say that medication has helped me immensely to break the panic attack cycle that was so debilitating, though I know you are not a fan.

    • Joseph Burgo says:

      I’m not entirely opposed to medication, but I don’t like the way it has been used as a substitute for psychotherapy. For limited time periods, medication definitely has its uses.

  11. JLB says:

    The stigma surrounding mental illness is a shame mostly because the people who desperately need help are the least likely to seek or be able to afford it. Recently a Senator in my state was nearly stabbed to death by his son, who then committed suicide. Perhaps if less stigma was attached to seeking mental health help a tragedy such as that may have been prevented. The United States definitely has a mental health problem cleverly disguised as a gun control problem.

  12. Fiona says:

    What you say is so true about the difficulty of using the term mental illness and the continuing stigma of the mentally ill. This came home to me recently- in this country a young man who was dying from cancer came out and said that young men were’ choosing’ suicide ( we have high numbers of youth suicide) and that they should appreciate their life. What was shocking about this wasn’t so much his attitude but that he got widespread support; only a few people challenged what he said (no professional challenged his views that I’m aware of).

    Anyway I realised that I’d been naive (I thought things were changing because there is more discussion and several celebrity types have come out about their struggles with depression/bipolar). Now I think this is more a veneer of understanding/sympathy rather than a real change. I think that the ‘mentally ill” have been the scapegoats of society – ‘they’re’ mad and we’re sane” kind of attitude still exists – a sick society needs the mentally ill just like a sick family needs a scapegoat IMO. While there’s scapegoating going on there’ll always be stigma. It’s very difficult for the so called mentally well people to accept their own mental illness ( I think we’re all more or less mentally ill) and they’d rather project their own issues onto others who are more obviously disturbed than accept their own problems, IMO.

  13. Dolma Beck says:

    Is gender socially constructed? What is it to be a woman? A man? These discussions, open up so many areas for thought/ discussion.

  14. Dolma Beck says:

    I am pretty sure, though, that my womb isn’t socially constructed.

  15. Kim says:

    Hello Dr, Burgo. This post addresses some of the issues that I have done lots of thinking about over the past 5-10 years. I am also glad that mental health stigma has been reduced (although not completely of course) over the last 20-30 years but it does seem that we have exchanged it for something just as toxic (or more toxic) which is the medicalization and “we can fix it” mentality we are now living under (as you point out). I practice primary care pediatrics and the care of mental health has been delegated to primary care providers who basically have no training whatsoever in the area of mental health. So we have 15 minutes to make a complex diagnosis and then are expected to give medicines which are not studied or proven to be effective in adults, let alone kids, and then we see them in a month to see how they are doing. It is patently ridiculous. We have completely capitulated on giving any kind of meaningful mental health care. Believe me, it is bad out there. First of all, it seems like the only treatment insurance will pay for is meds, and the meds can be toxic and at best have very flimsy data in support of their use. Second, if you manage to actually get someone into counseling they have 6 visits of CBT to fix a lifetime of shame and toxicity and trauma. It is so heartbreaking especially watching kids. There is no rhyme or reason to the cocktail that child psychiatrists put kids on (if you can manage to get them to a child psychiatrist which is rare). I’ve seen multiple kids on 1-2 anitpsychotics plus a stimulant for ADHD plus an antidepressant plus an antianxiety med. I am completely serious. They look like zombies. And almost all of the kids on antipsychotics like Risperdal or Abilify (yes kids this is an anti psychotic NOT an antidepressant) become obese and pre-diabetic or just plain diabetic. Now I see kids put on preventative Metformin (used to treat diabetes) when they are put on an antipsychotic to try and prevent diabetes when the kids inevitably become obese. It is crazy and infinitely so sad. I could go on and on. My main point is, I don’t think it is so much better now, and I’m not sure it is going to get any better. And what are we trying to fix anyway? Isn’t it part of the human condition to struggle, even struggle greatly, and overcome and grow? When did this become bad?? Is our goal to have everyone in a state of some sort of flat affected neutrality so we don’t bug each other?? We need to rethink this whole thing…..

  16. Gordon says:

    The more I think about mental illness, the more I think it’s in our nature to feel the core shame you describe. We inherit genetics, but we also “inherit” our culture and traits from our caretakers.
    I think one of the biggest drivers of sex is the avoidance core shame because while you are doing it you feel loved at a deep level (no clothes level at least) and this makes you think that maybe your core shame is not that noticeable after all.
    We make ourselves believe that if only we had this or achieved that we would no longer be defective and thus worthy of love. Then we achieve it and it works, but not for long. You get a high of feeling non defective at last, then you crash back into reality. It’s a drug and we get addicted. The only way to get more of this shame cloaking drug is by achieving more and getting more. Buying a Rolex, having sex, climbing Everest, having a child, becoming a philanthropist, etc.
    What would a life without any mental illness or core shame be like? Why would we want to achieve anything or procreate if we already felt perfectly worthy of love? Wouldn’t we just strive for that that feels good to our senses and become obese?

    I feel like I’ve just explained why obesity could be the result of perfect mental health… I must be rationalizing something here.

  17. Hattie says:

    This is regarding your very stimulating Atlantic Monthly article on narcissism and middle age, which you link to here. I worked for a narcissist for nearly five years as her 2IC. I’ll call her Sarah. Sarah ran a division in a large publishing company, and had a history of great success in bringing in revenue. By the time I arrived, though, she’d hit middle age, and her effectiveness had waned. She was the victim of her own success but also her self-obsession. She was so convinced of her ability to spot a bestseller that she had stopped reading the ‘zeitgeist’. Her lifestyle become so glamorous that she no longer had a sense of what regular people wanted to buy and read.

    During the first few years, I spent a lot of energy trying to ‘normalize’ her. I put in place proper workplace structures and processes. I mistakenly thought that these grownup formalities would make her less chaotic. It sort of worked for a while, but the destructiveness of her personality would invariably leak out. She’d tear staff members to shreds over minor matters, and make substantial changes to projects at the last minute. She’d travel first class on company expenses, then berate her team about overusing the colour printer. She’d take credit for other people’s ideas, play favourites as a means of control, and talk constantly about her life of luxury to people who were on a fraction of her salary. During my remaining years, I strategized to survive, nothing else. I have no idea why I stayed so long. I used to joke darkly about having battered wives syndrome. In retrospect there were element of truth in this. Like many victims of much more serious abuse, I was sustained by the illusion that I could change my persecutor.

    When I left I had mini breakdown and went into therapy. I’d stopped sleeping and started experiencing very high levels of anxiety. I couldn’t let myself collapse while in the job because the environment was so dangerously toxic. Since then, I’ve spent many a therapy session exploring a life-long tendency to take responsibility for other people’s behaviour. I realise I didn’t change this woman one iota; I made her look good by implementing processes that masked her true behaviour. In doing so, I most likely prolonged the agony of her tenure as head of her long-suffering team.

    The things that worked for Sarah when she was young – her charisma, and willingness to take risks – stopped working for when she hit her forties. The impetuousness wore thin; the constant self-referencing, once thought charming was later seen as boring if not desperate. Like you say in your article, we want more from the older people in society. We don’t want them having tantrums in meetings; we want them to lead by example, nurture talent, put the greater good ahead of personal ambition. Sarah is hanging on, I believe, but the tide has turned. I am now working in an astonishingly high functioning work environment, and loving it – but I still find myself having to tend the scar tissue.

    Thanks for the article – and for this wonderful blog. It never fails to stimulate!

  18. SK says:

    I have pondered how I would comment on this since you first uploaded this post but struggled with knowing how I feel about it. I’ve considered it, let it sit with me for a while and come back now with the view to sharing my opinion. I’m not sure if my ramblings will make much sense. I think part of the reason why I didn’t comment initially was probably something to do with the discomfort I feel in identifying with the shame and my reluctance to see myself as someone who suffers from mental illness. I wonder if many of your readers feel this way and that is why there are fewer comments on this post than previous ones? Or perhaps you just haven’t been online to upload them yet?

    I think the way I see mental health is less compartmentalised and less black and white than some (I don’t have a fixed opinion on this so am moulding my view as I type)… I don’t see it as an ‘us and them’ world where some of us suffer with mental illness and some of us don’t. If you imagine a spectrum, like a long line stretching into the distance either side of you. On the far left you would have what is socially considered as mentally stable and on the far right the most extreme form of mentally unstable (the standards of which are very different in different social circles and different countries, I am led to believe that America and Britain over medicate and over hospitalise; hiding away the unacceptable, shameful ‘nut-jobs’ – whereas in other countries people with mental health issues are welcome and accepted non-judgementally as part of ‘normal’ society).

    Anyway, back to my analogy – I believe we all sit on that spectrum and can fluidly move from left to right and right to left in a lifetime. Our position on the line can be affected by life experiences, childhood upbringing, things that we do and things that are done to us, by damage to the brain or chemical imbalances, drugs, important relationships, single moments, decades of abuse etc etc… I guess I believe the list of possibilities and variables is limitless. There is no way of knowing what we will experience in life, control is an illusion and no matter how hard we try to construct our lives to our liking we never truly manage to have things the way we want them all of the time. None of us have chosen the person we are, none of us chose our parents, our country of birth, our appearance, our gender, sexuality, personality, intelligence level, likes/dislikes… we are simply born into these bodies with these minds and to an extent we have to accept this. We do however have a responsibility over how we react and respond to these things. Do we let certain circumstances squash the life out of us or do we use them as ways of building our understanding of ourselves and the world? For years I crammed all my pain and anger inside of me thinking I had grown away from it (ignoring how it had cropped up in other areas of my life) but in my late 20’s I decided I did not want my ‘issues’ to negatively impact on my children’s lives like my parents did to mine. I actively did something about it – I chose to grow.

    There have been some episodes in my life when I have felt so far right on my spectrum of mental health that I’ve desperately wanted to be sectioned and then there are times when my mental health has been unquestionable stable. I believe we all have the capacity to veer drastically to the right or left and to a large extent it is out of our control. To me that means there should be no judgement of those who are struggling with their mental health and no shame for those who are struggling.

    Back to the shame of my mental health – do my friends and colleagues know I have suffered from depression and anxiety disorders? Do they know I have had periods of serious self-harm in my life? Do they know about my traumatic upbringing? The sexual assaults I experienced… the emotional neglect and abuse… Do they know I have spent the past 14 months in therapy dealing with all this? NO. Why do I choose not to tell them? I am not sure. Maybe I don’t want them to know that much about me. Maybe I think they won’t understand and will unfairly judge me because of their ignorance. Maybe I am worried that in periods of my life when I feel ‘well’ they will still remember the times when I was ‘not well’ and will treat me differently because of that. I am a private person and don’t share much with people (I guess that translates as ‘finds it difficult to trust’) so it would be completely out of character for me to share this information with anyone other than my husband, best friend and brother. In my opinion mental health is such an intimate thing, it would be like telling everyone when my husband and I last had sex… it’s none of their business and no one gains from me sharing, least of all me. Maybe I feel that it has taken me over a year to understand myself and for those who have not been through therapy they will not have the same understanding.

    I believe I do understand your views on core shame and it rings true with me. Embracing and exploring these things can only make sense if you have experienced in depth therapy. Before therapy I wanted to run and hide and push away the pain but now I can see how much personal growth can come from very closely exploring the most uncomfortable parts of me. My most meaningful sessions have been those where I am well out of my comfort zone, experiencing the fear in the security and safety of the presence of my therapist. This baring of myself to my therapist has been excruciating but the most liberating thing I have ever done – would it have the same healing power if I did this with everyone I met? Certainly not. Self-preservation, self-protection… these things are important to me. I don’t know if it is about mental health having a stigma or about me personally being very guarded. I will definitely talk openly to my children about mental health as I know the reason I suffered so much was because no one talked to me about any of this. No one told me I could talk. My door and my mind and my heart will always be open for my kids and my loved ones – a non-judgemental ear. The person I can thank for modelling that relationship to me is my therapist. Before him I didn’t know what it felt like to be accepted for who I am. If only more people were accepted for who they are (from birth) there would be a whole lot less externally enforced shame going on and therefore in my opinion a less core shame… but then you and my therapist would have a whole lot less work to do!

    Thanks again for a thought provoking few posts and sorry for the very long comment.

    • Joseph Burgo says:

      I agree with everything you say, especially the part about the spectrum of mental health. I also think that revealing oneself (and one’s shame) to a therapist and then feeling seen and accepted can be a healing experience. It doesn’t entirely erase the shame but it does help one move along that spectrum toward health.

  19. Joseph says:

    I’m glad I stumbled upon your work Dr. Burgo, this is one of the first of your posts that I have read and I will be continuing to read more. I’m a undergraduate student interested in the many aspects of personality & “abnormal” psychology (as well as some dabbling in philosophy). In a fatherless and role-model-less era, I can’t being to tell you how important your insights really are to those young intellectuals who are in the process of seeking a deeper understanding of the chaotic world we inhabit. I personally have very limited resources when it comes to interacting with great minds who are able to penetrate the mystique behind the human mind itself, so your videos and writings are invaluable, they instill a kind of hope in me that triggers the resounding thought that I am not alone — & not from some archaic tomb of writings with esoteric ideologies, but from a living, breathing being who is sharing this world with me as I write this.

    Thanks again,
    Joseph

    • Joseph Burgo says:

      Joseph, I’m so sorry to have taken this long to approve your comment. I was overwhelmed with finishing my book but I am backing to blogging now, and also to approving a backlog of comments. Thanks!

  20. Hermes says:

    It has been quite a long while since I’ve visited your site, Dr. Burgo, so I am busy (and fascinated and entertained) catching up on your articles and some of the responses. You are absolutely correct when you say:
    “This view of mental illness still prevails on the religious right — as in the claim that homosexuality is a “lifestyle choice,” for example, and that gays are obviously making the “wrong” one.”
    In general I believe that matters have improved, perhaps only in the last decade though. In my own country of origin, Ireland (I live in Europe) not that many decades ago a child born with a mental defect was (at best) kept locked away in the “room”, particularly if anyone was visiting the house. “Out of sight, out of mind” being the motto. The parents felt huge shame not to say horror at having engendered such a child, or worse still, they were made to feel such shame, and it is noteworthy that I am talking about a society at that particular time in the ferocious grip of a fundamentalist Catholic church. Not much sign of charity and understanding!

    Things have improved, somewhat, but in Ireland there is still great stigma attached to mental illness, yet no one admits to seeing a psychiatrist or psychologist. The attitude is to some extent understandable, as any mental illness is seen as a “weakness” and employers will not take on people who have, or are found out to have, for example, depression.

  21. DD says:

    I appreciate this blog. While I am interested in and have studied a great deal of the
    history of the mental health world and can emphatically say ‘Thank God!’ that
    I do not live in that world anymore and for the leaps and bounds of
    psychology/psychiatry…..I also still experience stigma on quite a large
    scale yet today and we have a long way to go, even in…or perhaps ESP
    in our modern, uber-independent American culture. I have complex ptsd
    w all the trimmings. If you say that to anyone, they immediately think of ptsd with the flashback and startle response, maybe insomnia and the general public automatically think veteran. First, those symptoms don’t begin to scratch the surface of complex
    ptsd. In fact I have begun to like the ‘disorder of extreme stress nos’ better, simply
    because it helps to differentiate it from ptsd singularly. (Thanks DSM-5
    think tank panel, for still not doing that even in the clinical world). That said
    I have read a lot of new information on ptsd. Even specifically on
    desnos, which is helping to enlighten people about the ‘disorder’. I love
    the new scientific, neurobiological evidence based research which has
    shown in brain scans, etc that the conditions are not just ‘a choice’. It was in reading such articles and research that I first came across the term ‘mental injury’. Wow. Talk about helping
    not just mental health professionals but those who suffer from these things
    to recognize that what happened to them actually changed their brain and how it works. To me, this kind of education is how we go from the stigmas of mental ‘illness’ or even
    ‘disorders’ to an understanding of them. Whether ptsd, bipolar, schizophrenia, and yes…even the horrible stigma that still exists surrounding personality disorders and self injury….education begets understanding begets empathy begets the environment of healing and/or life improving help that people with such things so desperately need. One of my favorite pieces of such education is a paper with captions on it. To the person
    with diabetes someone says “Can’t you just get over it and move on?” To the
    person with cancer “You’re just trying to get free medical care and food stamps.” To the
    person with MS, “Stop making excuses and get off your butt.” And at the
    bottom it asks, “What if se treated all illnesses like we do mental illness?”
    I’m sure I didn’t quote it perfectly but it gets the point across.
    I do personally understand the differentiation you are making here between societal
    shame and core shame. I would think that all core shame begins as societal though and
    that it is an early and deep seated internalization of such shame that then
    is personally owned by the person. Childhood sexual abuse almost always comes
    with some major screwed up emotional and psychological manipulations which
    use mass doses of shame to maintain silence. When you eat that for
    dinner almost every day….well, it gives new meaning to ‘you are what you
    eat.’ Thank you for recognizing the monstrosity of core shame. It is
    my most insidious demon that spawns all sorts of other little minions too. Like
    an impossible fear of needs and attachment and vulnerability, and an utter
    lack of words whilst seated across from this person that I really must trust
    and depend on. At least my therapist gets it. There are plenty of professionals that
    don’t. And if the pros don’t get it, there’s no way society as a whole will.
    I’ll hush now.

    • Joseph Burgo says:

      Core shame does not begin as social shame, although social shame often reinforces it at a later stage. You might want to read some of my many posts on this subject. My point is to distinguish the two, not equate them. There is a great deal of confusion about this issue.

  22. Susan B Journey says:

    I’m concerned that the psychiatric/psychological professions have completely abandoned rationality in their efforts to comfort or assuage the uncomfortable feelings (including what you call core shame) of trans-identified individuals. The fact is that homosexuality is a collection of feelings (sexual and emotional attraction to a person or persons of the same sex) which are in no way antithetical to reality: the heart wants what it wants. Trans-identificaiton, however, is a feeling (“I’m really a woman in a man’s body”) which is absolutely antithetical to reality – AKA a delusion. A male transwoman is demonstrably, measurably male (XY DNA, male sexual organs, male hormone levels, male musculature, male bone structure, etc.) No matter what he feels, no matter how strongly he wants it, he will never actually be female. Just as a sufferer of anorexia nervosa should never be able to persuade a medical professional that she (at 5’7″ and 85-lbs.) is “really fat” no male transwoman (with a measurably male body) should be able to persuade a medical professional – or any other rational adult – that he is “really a woman”. Maybe what he’s feeling isn’t core shame? Maybe there is a small part of his mind which realizes that he’s a male in a male body, but the mental health professionals around him are enabling his mental condition instead of actually helping him get well?

  23. Liz says:

    I really enjoyed reading your description of the difference between external and internal shame. Although I don’t feel very much external shame, I have struggled with intense internal shame for most of my life. I think that modern discoveries about mental illness have come a long way in reducing the external shame we feel in how we relate to others, but I’m still at a loss in reducing the inner shame of having a mental illness. We are taught that our brains make us who we are… So if there is something wrong with our brain, isn’t that the same as having something wrong with who we are? I was diagnosed with ADHD as a child, which started my long battle with shame. Even at 10 years old, I realized that if there is something wrong with your brain, that there is something wrong with you, despite how others may tell you that it’s not your fault. Along with future diagnoses of Depression and Anxiety disorders, I have never been able to stop feeling shame for who I am, and wishing that I could just be normal. Despite being successfully treated with medications, I often wonder if they are changing who I am (they certainly are to an extent). This leads me to question who I really am, how I should really be, and if I am even an authentic person. Maybe the only way to end this shame is to look at mental illness more similarly to how we look at homosexuality or transgender. Rather than medicalizing it as a disease, we should look at it as variations of normal human behavior, and value it as such.

    • Joseph Burgo says:

      For me, shame IS the awareness that something about you is damaged or defective.

      Healing in my view does not come from redefining mental illness as “normal” but through healing relationships where one feels known, loved, and accepted. That being said, I also believe some degree of shame will linger on, but it won’t be so toxic or utterly defining. I still have some shame about certain aspects of myself but it doesn’t rule me.

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