Abstract
This article highlights the importance of recognizing and working with shame when clinicians are supporting families who have experiences of developmental trauma. This article will help clinicians identify the existence of shame in parents, children, and therapist; differentiate shame from guilt; understand the connection to developmental trauma; and draw information from case examples. This article draws from clinical wisdom and experience, providing possible interventions that may be helpful with this population. Recommendations for future research are also discussed.
Keywords
Children who have been exposed to developmental trauma can be left at risk for increased struggle, mental health challenges, substance use disorders, and relationship difficulties during childhood, adolescence, and adulthood (Cook et al., 2005; Schimmenti, 2012; Van der Kolk, 2015). When a child presents with developmental trauma for mental health treatment, inclusion of their families is commonly identified as an important component of healing (Blaustein & Kinniburgh, 2018). Families with a child who has experienced developmental trauma have a higher likelihood of parents having their own trauma history, and the intergenerational nature of trauma is well-documented in the literature (Cook et al., 2005; Lünnemann et al., 2019). One of the emotions that can result from experiences of developmental trauma is an intrinsic sense of shame or worthlessness (Cook et al., 2005). In families where parent, child, or both has had traumatic experiences during development, several family members may be experiencing a high degree of shame in their view of themselves and in relation to each other (Lee, 2001; Schimmenti, 2012). Specifically targeting shame when working with families who have experienced developmental trauma, therefore, may be a worthwhile endeavor.
This article conceptualizes the related factors of (i) shame, (ii) its relevance to family therapy with children and parents, (iii) in a family system which has experienced developmental trauma. A search for appropriate interventions targeting shame for this population uncovered few articles that explored all three topics together. The literature that did exist called for more research in this particular area (Amoss et al., 2016; Saraiya & Lopez-Castro, 2016; Taylor, 2015). This gap may be partly due to the fairly recent inclusion of shame as part of the diagnosis of post-traumatic stress disorder (PTSD) in the latest version of the Diagnostic Services Manual (DSM-5; Taylor, 2015). Existing literature targeting shame typically reviewed adult survivors or group therapy (Brown, 2006; Shahri, 2014; Sweezy, 2011) without addressing the family system. In order to explore this topic, three literature searches were conducted to understand the connection of shame to trauma (including developmental trauma), the overlap of shame and family therapy, and a final search including shame, trauma, and family therapy. The terms “developmental trauma” and “shame” are first defined to ground the remainder of the article in an understanding of the terms used. A composite case study that illustrates the theory in practice is used to ground the theory. The literature review discusses the literature available pertaining to the subject. An intervention section provides suggestions for implementing theory in practice, which is followed by a conclusion that provides suggestions for future research.
Definition of Terms
Developmental Trauma
Developmental trauma (also referred to as complex trauma) represents the impact or disruption to typical healthy development in infants and children, due to chronic exposure to forms of abuse or neglect during infancy or childhood (Cook et al., 2005; Schimmenti, 2012). The types of experiences leading to developmental trauma may include abandonment, neglect, physical or sexual abuse, emotional abuse, witnessing violence, including exposure to domestic abuse, suicide, or death (Schimmenti, 2012). These types of experiences, over a period of time, often result in a disruption to a secure attachment relationship between children and their primary caregiver. A secure attachment is widely considered essential to a child’s development of emotional regulation, achievement of developmental milestones, social skills, concept of self, and value to others (Cook et al., 2005; Shahri, 2014). Experiences of developmental trauma impact the developing brain differently than trauma experienced by an adult (Cook et al., 2005). Developmental trauma, although not formally represented in the latest version of the DSM-5, is widely regarded by academics and clinicians as a useful term when considering the unique presenting symptoms related to repeated exposure to trauma in infancy and childhood (Cook et al., 2005; D’Andrea et al., 2012). Developmental trauma is distinct from the diagnosis of PTSD in that it captures the unique difficulties associated with exposure to trauma in the developing infant and child’s brain, and the effects of that exposure on development and functioning (D’Andrea et al., 2012).
Children who have been exposed to developmental trauma can be left at risk for increased struggle including interpersonal challenges, sensory-motor development difficulties, somatization of stress, affect regulation difficulties, dissociation, low impulse control, cognitive difficulties in executive functioning, impulse control, as well as poor self-concept (Cook et al., 2005; Schimmenti, 2012; van der Kolk, 2015). Children may present with challenges such as inattention and hyperactivity, learning disorders, negative self-talk, difficulties socially, a heightened sense of alert and self-soothing techniques using masturbation or feces (Cook et al., 2005). Childhood trauma is also linked to negative physical health outcomes later in life (Banker et al., 2019).
As developmental trauma includes children’s maturing brains developing in an environment without safety, this can lead to hypervigilance about perceived safety in the world. Developmental trauma includes a constellation of symptoms; however, a common characteristic of a child’s experience is that much of their time is spent in a state of either hyper- or hypoemotional arousal. This may lead to children seeming “on edge,” with symptoms of hyperactivity, impulsiveness, emotional dysregulation and anger outbursts, or times of dissociation, detachment, and avoidance. As these experiences frequently begin in an early period of a child’s development, the experiences are imprinted upon the developing body in implicit memory. In short, the body keeps its own record of traumatic experiences, even if not cognitively understood or remembered in a linear sequence (van der Kolk, 2015).
Shame
Shame is described in the literature as an emotion that is focused on perception of self, often in a context of relationships (Saraiya & Lopez-Castro, 2016; Schimmenti, 2012). Shame is defined as an emotional process of internalized, negative self-concept (“I am bad”) as opposed to guilt, which can be understood an (also negative) evaluation of an action (“I did something wrong”; Saraiya & Lopez-Castro, 2016; Sweezy, 2011). Shame is thought to serve a function of interpersonal self-appraisal that helps children learn to be in relationship with others (Loader, 1998). When the healthy function of shame is activated, an individual appraises self and finds negative aspects of self but is able to accept these as part of themselves (Loader, 1998; Taylor, 2015). However, when an individual experiences shame at a high level, through traumatic experiences, over a prolonged period, or it is directed at a child from a caregiver, this can weaken one’s self-concept, leading to the conclusion that the self is un-loveable, unworthy of love and connection, and that there is a deeply deficient component at one’s inner core (Loader, 1998; Taylor, 2015). Intrapersonal shame is another way children experience shame and relates to a sense of a defective self in interpersonal relationships and more widely, an experience of shame due to stigma or humiliation from a wider social system (Taylor, 2015). As shame has an evaluative component, cultural expectations for social roles and behavior impact how shame is experienced and it varies greatly between cultures, families, and individuals (Taylor, 2015). While guilt is considered more pro-social and prompts humans to repair interpersonal problems by making amends, shame can become toxic, as it often causes individuals to isolate and consider themselves deeply unworthy of their interaction or interpersonal offerings (Lansky, 1991; Sweezy, 2013). Humans attempt to regulate the painful emotion of shame in several ways to reduce suffering. A shame compass provides a visual; the north–south arrows pointing to the urge of using aggression to oneself (can lead to depression) and to others (anger, violence; Nathanson, 1997). The east–west arrows represent the urge to hide from self (using addiction, distraction or dissociation), and to hide from others (isolation; Nathanson, 1997). These four impulses are adaptive in the short-term and can result in a relief of the emotional experience, but over the long term often serve to create, reinforce, or repeat shameful experiences and reinforce a deep sense of unworthiness (Unthank, 2019).
One coping strategy for shame that may provide relief to children in the short term is a disconnection from experiences held in the body (Kreidler et al., 2000). Over time, this can lead to a pattern of disconnection from the bodily sense of shame, and eventually, most emotions (Kreidler et al., 2000). Disconnection from one’s emotions can contribute to difficulties with developing the skill of identifying, naming, and regulating these emotions as they arise. Later in life, this inability to regulate emotions may lead to use of substances or bottling up emotions until explosive anger occurs, damaging relationships (Kreidler et al., 2000). As shame is an individual experience, there are many ways children try to regulate shame, including showing contempt for others, asserting power, self-defeating, perfectionism, withdrawal or denial, hiding, rage, transfer of responsibility, humor, denying experiences of shame, and when all else fails—mortification (individual accepts and exclaims that they are deeply unworthy; Loader, 1998). Mortification may further lead to self-attack, splitting, and self-defensiveness (Loader, 1998).
Therapist and Case Details
Location of Author A
While working as a family therapist in a children’s mental health agency [city], I (Author A) began to grapple with concepts of shame and developmental trauma in therapy sessions. I started to notice that shame would appear as a theme in the families where developmental trauma had been experienced by the child, the parent as a child, or both. Once I started noticing shame, it became clear to me that shame was appearing in many forms—either explicitly named by the parent, in the form of children saying shameful things about themselves, or in myself, in feeling inadequate as a therapist to respond to and contain these emotions. These experiences led me to explore this research on shame and its connection to developmental trauma in family therapy.
Composite Case Study
What follows is a composite case study of many families that received services at the agency over a period of approximately 1 year. All identifying information as well as facts about cases have been combined, changed, and obscured to ensure anonymity.
Suzy, a 9-year-old female, is the eldest child of her biological parents who have their own distinct trauma histories from childhood. Suzy has younger twin brothers who are 5 years old. Suzy experienced several early traumatic experiences, which contributed to a constellation of symptoms categorized as developmental trauma. Suzy had witnessed intimate partner violence in her early developmental years and was cared for during that time by her mother who was then struggling with a substance use disorder. Suzy and her parents were referred to myself for family therapy. Suzy was reportedly acting aggressively at school and at home when she became dysregulated, raising her voice, running away and disrupting classrooms, pinching or hitting other children. Parents reported a desire to have Suzy receive therapy in order to help her overcome these behaviors.
Suzy’s parents reported that they had resolved their differences before Suzy’s younger twin brothers were born. Suzy’s father had received counseling for anger, and Suzy’s mother had received counseling for substance use and had remained abstinent since Suzy’s brothers’ birth. Parents noted that they were currently finding it difficult not to have conflict in front of their children, and at times, they had arguments that escalated to screaming matches while Suzy was present. Parents also reported that Suzy had “low self-esteem,” as seen in such statements to parents as: “I’m a bad kid, I never do anything right.” I began meeting with Suzy individually and with parents on their own. During one of our parenting sessions, Suzy’s father told me: “I have a lot of shame from the past,” and Suzy’s mother reported: “I feel at a loss.” As I continued working with this family, it became clearer to me that shame was a theme for this family.
Literature Review
The connection between shame and trauma in a developing human mind can be understood by reviewing the reactions of the human nervous system under traumatic stress. The nervous system herein referred to is comprised of the parasympathetic nervous system (PNS) as the rest and relaxation branch, and the sympathetic nervous system responsible for fight/flight survival responses (Rothschild, 2017). When a traumatic event occurs, the concurrent activation of both systems results in confusion and distress in the body as the body experiences alternating urges to at once calm itself and also enter into survival mode (otherwise known as flight/fight/freeze reactions; Rothschild, 2017; van der kolk, 2015). Porges’s (2017) poly-vagal theory further explains the impact of trauma on the body by presenting an understanding of the PNS as two further branches—the social engagement system (ventral vagus complex [VVC]) and the freeze system (dorsal vagus complex [DVC]). Shame can be understood as experienced when an individual has an impulse (unmet social needs), which activates the VVC (or social engagement system), and this impulse becomes blocked by the environment, leading to a simultaneous activation of the DVC (freeze system; Shahri, 2014). For an infant or young child, this would be experienced as instinctively reaching out and asking for a need to be met and then experiencing this need as unmet or thwarted by the environment/caregiver (automatically mobilizing the freeze response) to stop the request or impulse from taking place. This experience may result in an imprint on the developing body of the feeling that these automatic impulses to reach out to others are bad/wrong (shame) or that these impulses for connection accompany intense feelings of fear (Shahri, 2014). Children may also experience a pattern of disconnection from emotions and sensations as the DVC disconnects the mind from the body in order to react instinctively in a protective survival mode (Shahri, 2014). A child’s budding sense and understanding of self and self-worth relies heavily on attachment figures meeting basic comfort, safety, and survival needs (Shahri, 2014). Early attachment relationships to primary caregivers give a child the message: ‘you are good, your needs are important and worthy of being met’ (Cook et al., 2005; Shahri, 2014). In contrast, repeated disruptions of attachment which are often experienced in developmental trauma, send the opposite message: ‘you are unworthy, your needs are problems, you are a problem’ (Shahri, 2014).
These early experiences may lead a child to swing back and forth between their instincts of reaching out for attachment and social engagement and protecting themselves with fight/flight/freeze responses (Fisher, 2017; Schimmenti, 2012; Shahri, 2014). Essentially, the brain is focused on keeping the infant or child safe, and this becomes its primary objective above other needs or developmental milestones (Toof et al., 2020). The concept of the “window of tolerance” is used with many who work with individuals who have experienced developmental trauma to demonstrate that trauma survivors are often hyperaroused (fight/flight) or hypoaroused (freeze/dissociative; Fisher, 2017; Rothschild, 2017). The window of tolerance represents one’s ability to be regulated, with the body feeling safe, when survival instincts do not need to be activated. In children who have experienced developmental trauma, the window of tolerance may be quite narrow (Cook et al., 2005; van der Kolk, 2015).
It is important to acknowledge that shame serves an important evolutionary function in children who have experienced developmental trauma—shame functions to urge children to maintain connection with caregivers by driving the sense that something is deeply wrong with their behavior. As developmental trauma often occurs within dependent relationships, a young child has very little control over the adverse experiences to which they are subjected (Lyons et al., 2015). If the center of blame for their terrifying and confusing experiences becomes associated with themselves through shame, this initially also makes it easier to withstand emotionally in the short term, as they regain a sense of control or agency over the situation “if I am the problem, then I can control the problem” (Lyons et al., 2015). Aggression can also be very effective as a short-term means to regain a sense of control. However, the repeated use of anger can result in interpersonal interactions that are misunderstood by others as intentional misbehaving rather than attempts to control what is perceived as an unsafe situation. The behavioral punishments which may be given in reaction can reinforce a child’s sense of unworthiness (Schimmenti, 2012). Although shame is adaptive and can result in short term relief of an overwhelming situation, when prolonged experiences of shame become reinforced over and over it becomes a less helpful survival resource (Ogden et al., 2006).
Unthank (2019) proposes that adult trauma survivors link the vulnerability necessary for close bonds with others to feelings of intolerable shame and fear rather than support. An individual then becomes stuck when relationships require vulnerability, as they react to the need for vulnerability by continually perpetuating violence toward themselves and others in order to regulate shame and fear that are linked to vulnerability (Unthank, 2019). In the short run, the violent reactions can result in a person feeling somewhat regulated, and an instinctive longing for wholeness and interpersonal trust is then returned. Relationships are attempted again, but when vulnerability inevitably becomes required to strengthen relationships, this can be experienced as an extreme threat to safety, and the avoidance/aggression urge and corresponding action occurs again (Unthank, 2019). This perspective on trauma survivors and the attempted regulation of shame may shed light in a family system where members reach toward each other and then apart in self-protection when vulnerability becomes too terrifying.
Fisher (2017) found that adult survivors of childhood trauma often describe a sense that they have two modes of being in the world. One is their trauma response mode of responding to events and relationships, based on instinctive fight/flight responses. The other is the “functional” mode of being that allows for the steps and actions needed to participate in daily life in society. Fisher (2017) found that clients often describe a sense of shame that the trauma part of them is their “true” self, and their ability to live life and function outside of this is “false.” Fisher (2017) relates this phenomenon to early experiences of imprinted shame on the body, then the cycle of shameful reinforcing experiences, convincing adult survivors that their trauma responses are who they truly are and attempts to respond in alternative or more helpful ways are “fake.”
Trauma responses that are reinforced early on in the developing body and brain may be recreated and reinforced in family systems. According to Lee (2001), shame in family systems serves as a signal that needs or desires are unmet. A child’s unmet needs and resulting shame-regulating strategies often trigger parents’ unmet needs and resulting shame-regulating strategies (Lee, 2001). This can lead to a cycle of reactions grounded in a self-protective instinct of wanting to regulate shame, at times causing both caregiver and child to become dysregulated, often increasing the intensity of conflict (Lee, 2001). Toxic shame occurs in families when shaming is done for the benefit of the caregiver’s need for regulation and to the detriment of the child (Loader, 1998). Loader (1998) proposes that intentionally shaming the child may serve several functions for parents including raising a caregiver’s self-esteem through putting down their child. Messages may come in the form of direct comparisons of child to caregiver or unrealistic expectations of children followed by a message of disappointment (Loader, 1998).
Caregivers may also be particularly aggrieved when they perceive failings or weaknesses in their child, which may mirror their own, transferring parent’s own shame about their weakness to the child (Loader, 1998). Caregivers who felt unsafe as children may be attempting to stamp out perceived weaknesses on the part of their child in order to have child become tough enough to withstand difficult experiences in the world (Deblinger & Runyon, 2005). The result of toxic shame in parenting can have children finding themselves caught between two unsatisfied needs. Children learn that they can either appease parental expectations while dismissing own needs/identity or they can develop their own identity/fight to fulfill their needs but their need for parental approval may remain unmet (Loader, 1998). Parents in family therapy sessions may reexperience shame if they were involved as perpetrators or they were part of the dynamic that led to their child experiencing developmental trauma (Lünnemann et al., 2019). Parents may experience therapeutic interventions as blaming and seek to regulate the experience of shame by directing their anger at the therapist (Lee, 2001). When shame appears in the context of parents sharing hopelessness about their own effectiveness as parents, or their involvement in their child’s developmental trauma, this alerts the therapist that the parents need emotional support targeted toward shame (Lee, 2001).
Case Study Anecdote: Shame Triggers in the Family
In Suzy’s family, parents reported that they often responded to Suzy’s perceived “out-of-control” behavior with more efforts to control Suzy’s behavior with consequences and raising their voice. If her parents had been able to understand Suzy’s emotional dysregulation and attempts to take control of her situation as her way of regulating her feelings of shame, Suzy’s parents may have been able to respond with firm warmth while maintaining their emotional connection with their daughter. However, as parents became triggered by Suzy’s behavior, they reported feeling a threat to their own sense of safety and control. As Suzy’s need for control was triggering the parental need for control, all of the family members became dysregulated and conflict escalated.
Suzy’s parents reported also feeling completely overwhelmed and in need of support. Suzy’s parents rejected the possibility that their daughter’s emotional difficulties might be partly explained by (i) Suzy’s exposure to past violence and ongoing conflict and (ii) substance use of mother during Suzy’s early experiences which may have caused the parents to experience shame. This shame was noticeable when the parents (i) expressed a wish to find alternative medical explanations, as well as when (ii) the parents found it difficult to contemplate shifts in their own responses.
Shame in Therapy—The Therapist’s Counter-Transference Response
The feeling of shame is difficult to share with others for many reasons (Fisher, 2017; Schimmenti, 2012). Shame is at times shared using lighter, more socially acceptable feeling words such as “humiliated” or “embarrassed.” If the roots of deep-seated shame are embedded in developmental trauma, shame may also be held in the body as implicit memory and therefore not consciously present for the client or family to recognize without assistance (Schimmenti, 2012). Unfortunately, therapists do not always acknowledge or even notice the presence of shame in themselves or their clients (Cavanagh et al., 2015; Schimmenti, 2012). When therapists avoid shame, the therapist can unknowingly send a message to the client that the emotion of shame is dangerous, too complicated for the therapist, or that there must be something very wrong with the client if the therapist cannot tolerate this part of themselves (Schimmenti, 2012). The other danger of ignoring shame is that the therapist may become frustrated or feel stuck in the therapeutic relationship, resulting in more shame for themselves, “I’m not experienced enough for this level of complexity,” and shame for client: “I’m un-helpable.” Shame is a particularly difficult emotion to contend with in the therapy room because the therapist may have their own defenses about shame which they have learned through their life. These defenses may be similar to a client’s defenses, which means together they may end up colluding together to avoid feeling shame (Cavanagh et al., 2015; Wallin, 2007).
Therapists may also experience an emotion of disgust toward a client, particularly in reaction to content related to developmental trauma (Cavanagh et al., 2015; Wallin, 2007). The therapist may try to avoid or deny the presence of this feeling, as it may seem contrary to the professional, nonjudging stance (Cavanagh et al., 2015). However, by not allowing themselves to feel disgust, the therapist is potentially shaming themselves for their own emotional experience and may miss important information in the process (Wallin, 2007). Wallin (2007) states that therapists must use their own bodily and emotional information to better understand themselves and client/family and to notice all the information they are given in a session. Wallin states that since attachment relationships are formed in a pre-verbal context, the attachment relationship formed in therapy is often enacted in a nonverbal way. To ignore these cues interrupts the bonds necessary to do the work (Wallin, 2007). Another reason therapists may unwittingly avoid shame is because the complex emotion of shame may be intimidating to a clinician out of fear of what the shame may bring forth in clinician or client or perhaps a fear that the clinician may not be able to contain it (Schimmenti, 2012). This tendency to avoid the deeper or strong emotions may be an indication that the therapist feels uncomfortable going to a deep emotional place themselves and therefore is trying to save the client from something that the therapist themselves finds difficult and uncomfortable rather than providing the client with the experience of release through processing the emotions (Schimmenti, 2012).
Case Study Anecdote: Therapist’s Countertransference
I experienced a countertransference of shame when working with Suzy’s family that, in retrospect, I would have responded to differently. In the course of working with Suzy’s father, he told me: “I have shame from my actions in the past.” Even though he explicitly stated the word “shame” aloud, I shied away from exploring this feeling with him. At the time, I said to myself, this is not related to what we are talking about (parental responses to Suzy’s emotional dysregulation), but in reflection, I remember noticing a feeling of a pit in my stomach when he said the word “shame” aloud. I believe, upon reflection, the word itself invoked a reaction of shame and fear in me, of going deeper into the emotion, of what that might bring up for me, and of feeling inadequate as a new therapist in containing the emotion in our session. In retrospect, I would go back to that theme and explore it with this parent. I would also allow myself to notice the bodily sensations of the pit in my stomach, feel the fear and shame, and proceed, even though this might seem uncomfortable to me. In shutting down the conversation after this parent had been so vulnerable with me in sharing this feeling, I likely unknowingly provided them a message of: “your feelings are not important in this system, or, your feelings are too complicated for me to handle” and I unknowingly may have replicated their own childhood experiences of being shamed. By ignoring their feelings in favor of a more concrete intervention, I may have sacrificed a piece of the work that may have led this parent to connecting their shame and attempts to regulate it using anger with the impact on their child and consequently their child’s behavior. Unfortunately, circumstances with this family led to a rupture in the relationship with the father soon after. I believe unaddressed shame was part of the reason that our relationship could not withstand the circumstances that led to breakdown in the therapeutic relationship. My relationship with this father, over time, was repaired. I believe what helped in this circumstance was my increased ability to work with shame. I believe that this father felt misunderstood and blamed during the rupture. In order to repair this rupture, I first needed to be in touch with my own reactions to the father and to my own experiences of shame in the therapeutic relationship. The path to repair began with my identifying for myself that I was blocking a deeper exploration of shame due to my own fear of feeling inadequate in containing shame once it had been named. Only through recognizing this myself and learning to tolerate and accept the uncertainty and uncomfortable feelings associated in moving toward the father’s shame was I able to take steps to repair the relationship. Validation of anger, as well as intentionally naming the shame associated with his experience, allowed this father and me to repair the trust that had been broken.
Possible Interventions
This discussion of shame is not complete without an inclusion of possible interventions to approach shame in families who have experienced developmental trauma. Given the lack of explicit literature in this area, and the need for this discussion, the research for this article did not locate any specific modalities that specifically target this topic. Rather, what follows is a collection of findings, clinical experiences, or practice wisdom of clinicians, from using approaches to shame and general practices for approaching families with developmental trauma. Social work’s nature as a highly personal and relational career means that practitioners hone a valuable “practice wisdom” over years of practice which may be drawn on to inform practice, may be instrumental in moving a theory or approach forward, and can drive forward research agendas (Cheung, 2016; Samson, 2015).
Safety First
Any modern intervention targeting trauma-related symptoms explains that establishing safety in the therapeutic relationship is key to any treatment being effective (Fisher, 2017; Roshschild, 2000). As children with developmental trauma often swing between hyper- and hypoarousal, they would likely be highly dysregulated and unable to take in any information or intervention without safety first established and then continually prioritized during therapy (Blaustein & Kinniburgh, 2018). It is the therapist’s imperative to slow down the pace in sessions and recognize that the stabilization and safety within a child’s system are more important than therapeutic or behavioral goals of the clinician or the caregivers, therefore offering the potential for a better outcome (Blaustein & Kinniburgh, 2018). The Attachment, Regulation and Self-Competency (ARC) model recommends routine in every aspect of a child’s life when they have experienced developmental trauma. Such a structure of routine includes routine at beginning and ending of each therapy session so the child knows what to expect each time they are present for therapy (Blaustein & Kinniburgh, 2018).
Start With Caregivers—Repair and Strengthen Attachment Relationships
Beginning with caregivers with the goal of improving attachment relationships is consistent with models of therapy focused on children’s mental health and treatment of developmental trauma that have emerged in the past several decades (Blaustein & Kinniburgh, 2018; Hughes et al., 2015). For example, the ARC model operates from a foundation of (i) strengthening the relationships between caregivers and children, (ii) improving safety and stability in the family system and wider systems that the family operates, and (iii) helping support caregivers in understanding their child’s responses as self-protective and adaptive, not behavioral or manipulative (Blaustein & Kinniburgh, 2018). Dyadic developmental psychotherapy (DDP) is another intervention that recommends beginning with caregivers to provide psychoeducation and alternative ways of responding to children with curiosity and empathy (Hughes et al., 2015). DDP encourages parents to accept all emotions including shame, teaching parents about the common shame regulation patterns seen in children (Hughes et al., 2015). In both DDP and ARC, caregivers are taught to connect and repair relationships after a rupture, which can be instrumental in helping to combat shame (Blaustein & Kinniburgh, 2018; Hughes et al., 2015).
Lee (2001) recommends the locus of intervention start with helping caregivers identify their own shame triggers and relational needs to encourage the ability of parents to respond in alternative ways to children’s shame triggers and relational needs. For each family, factors such as culture, religion, race, age, location, and other aspects of identity and family identity will play a role in determining a family and individual understanding of the term shame (Taylor, 2015). Therapists must collaborate with families to come to an understanding of this emotion together and to find the word that best fits for them. Brown (2006) found that the naming of shame allows for opportunities for emotional connection, as it is no longer a problem with the self but a barrier in the urge to emotionally connect with others. Common shame signals to therapists include lack of eye contact, slumped posture, and laughter incongruent to subject matter (Schimmeti, 2012; Shahri, 2014). Lohrasbe and Ogden (2017) recommend parents make eye contact when repairing with children to help combat shame.
Resiliency and Connection
A focus on resiliency is recommended for trauma survivors in general including children who experience shame with a history of developmental trauma (Blaustein & Kinniburgh, 2018; Hughes et al., 2015). Strengths of the parental system can be reflected back by the therapist and built upon to give the family system a feeling of momentum (Blaustein & Kinniburgh, 2018). Focusing on ways in which children already show strength specifically in relation to social skills and connection with others will help to combat shame (Hughes et al., 2015). Helping to encourage and build wider community and familial connections is key to supporting a child to develop a sense of skill in regard to relationships (Blaustein & Kinniburgh, 2018). These goals can be achieved through strengthening bonds with other adults in a child’s life at school, in the community, or in the extended family, as well as involvement in extracurricular activities (Blaustein & Kinniburgh, 2018).
Several trauma-focused modalities narrow in on the importance of developing alternative and resilient narratives (Blaustein & Kinniburgh, 2018; May, 2005). Developing and strengthening narratives with children about their ability to follow rules, be engaged, have friends, get along, helps combat shame-filled narratives (May, 2005). These alternative narrative approaches help support the development of any competence that runs contrary to the idea of “I’m unlikeable, nobody wants me, my feelings are not important” (May, 2005). Trauma-focused cognitive behavioral therapy (TF-CBT) also includes supporting children in forming their own narrative about a traumatic experience that is balanced and can recognize their strengths (Cohen et al., 2004). TF-CBT, with modifications such as a greater emphasis on stability and safety during the first stage, may be appropriate for some families who have experiences of developmental trauma (Boyer, 2019). However, therapists must be cautious if using exposure interventions, as while they can be useful for combatting fear, exposure may be less useful for dealing with shame, and may cause more shame if they fail (Lee, 2001).
Using the Body
As the body stores memories and triggers for children who have experienced developmental trauma, it is useful for therapists to use the body as a source of information and a resource in therapy for this population (Fisher & Ogden, 2009; Ogden et al., 2006; Rothschild, 2000, 2017; van der Kolk, 2015). Relating present experience of the bodily sensations to increase tolerance in the present is the goal, prior to, if ever, processing the past (Ogden et al., 2006; Ogden & Goldstein, 2017; Rothschild, 2017). Shahri (2014) suggests that “body-based” interventions are important when children have a sense of disconnection from the emotions they are experiencing and that interventions for shame should try to reconnect the emotions and the body so that an individual can stay present in their body and stay emotionally regulated. To that end, grounding exercises, breath-work, and noticing the body is recommended (Shahri, 2014). This may involve supporting children in noticing what the body is feeling when in certain emotion states and helping to build a “feelings” word vocabulary (Blaustein & Kinniburgh, 2018; Shahri, 2014). Ogden et al.’s (2006) sensorimotor therapy teaches caregivers body-based skills such as paced breathing and grounding tools to assist caregivers in remaining in their window of tolerance so that they may help their child regulate (Lohrasbe & Ogden, 2017). Lohrasbe and Ogden (2017) recommend that parents and children engage in activities together to regulate. For example, therapists can encourage caregivers and children to practice together the paced breathing activities to slow down their heart rate, intentionally relaxing areas of the body where tension is held, such as relaxing the jaw or engaging in an energetic activity such as jumping jacks or bouncing on a ball (Lohrasbe & Ogden, 2017). In this way, parents and children together are increasing their ability to regulate and calm themselves, creating a calmer family environment. In addition to these activities, when used appropriately and safely, a calming and supportive touch from the caregiver may help in a child regulating their bodily felt sense of their emotions (Lohrasbe & Ogden, 2017).
Conclusion
In family systems where members have had experiences of developmental trauma, shame cannot be ignored. The available research demonstrates that shame often underlies behavioral symptoms that cause conflict and reinforce shame-filled identities. Shame, when ignored by therapists, can result in doubly shaming both clients and therapists. Currently, specific interventions that target shame in the context of family work with developmental trauma constitute a small part of the several models targeted at working with this population. More theoretical and empirical research in this area is required. There is room for the modification of existing family systems and trauma-focused interventions to better allow therapists to address shame in family therapy. An important tool that the therapist has available to themselves is the use of their own somatic responses as well as strengthening their client’s somatic experiences. Therapists can and should use themselves by paying attention to counter-transferences in order to effectively identify and work with shame.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
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