Hiding in Plain Sight: Chronic Shame in Clinical Practice

by Jan 6, 2023

In my clinical practice I see a thread of chronic shame woven throughout the fabric of life of many of my male, or male identifying clients; a thread just waiting to be plucked that sets in motion a degree of dysregulation and personal pain that will be avoided at nearly all costs. The difficulty is that this thread is most often initiated in their most intimate relationships— those of deep love, that are most precious, including their relationship with those tender, routinely disavowed wants and needs within themselves.

Many definitions of shame/chronic shame exist, and those which ring most true for me attempt to describe with heart the wholesale dysregulation, destruction, and attack on the very core of the person that shame elicits. Patricia DeYoung (2015) defines chronic shame as “one’s felt sense of self disintegrating in relation to a dysregulating other” (p. 18) and Dorahy (2015) includes the desire to hide, disappear or even die. For those who experience chronic shame, these descriptions begin to describe what it feels like psychologically and neurophysiologically when activated.

It’s important to differentiate between shame and chronic shame. Chronic shame appears much earlier than shame; first seen in the 2nd year of life, prior to conscious memory, remaining in a wordless state (Hill, 2015). The dysregulation experienced by the child is “”affectively burnt in” the infant’s developing right brain” (Schore, 2014, p.390), becoming a thread that is waiting to be picked, touching “a wound made from the inside by an unseen hand” (Kaufman, 1989, p.5), that reverberates throughout one’s interpersonal life. Additional research by Schore (2017) shows that male children are at increased risk for a number of psychopathologies because of slower brain maturation, particularly on the right brain, which leaves them vulnerable longer to negative experiences, particularly relational trauma that form the fabric of shame.

For those with chronic shame, integrated strategies for avoiding and surviving shame (Hill, 2015) are woven into the client’s Internal Working Model (Bowlby, 1973) – the way that people see themselves, the world, and their place in it. If we add to this Daniel Siegel’s (2010) assertion that ‘the brain is an anticipation machine’, we can see why chronic shame states are so incredibly enduring, and that no matter how safe or stable things are in the present, the thread of chronic shame remains active, and when activated, the same neural affective states that were experienced as a child are re-experienced by the adult client. We must remember that because chronic shame is formed prior to declarative memory, it exists outside of the conscious memory system, leaving it largely impervious to cognitive therapies, rendering clients baffled by the repetition of these intensely dysregulating interactions.

The benefit of bringing shame more into our clinical awareness, is that it can shift our focus from simply attending to behavioural issues and patterns—addictions, disengagement, anger, perfection, procrastination, pleasing—and begin to see the role that chronic shame, which is often dissociated from the client’s awareness, is having on initiating or perpetuating these patterns, and focus not just on the fire, but the fuel that is feeding it.

Clinically, I see two common expressions of chronic shame that are often used unconsciously and interchangeably by the client. The first is to internalize the shame and implode or collapse in on themselves, feeling the full weight of the humiliation or mortification embedded in the affective states of their nervous system and psyche. The second is to externalize and attack the interpersonal other, feeling the grandiosity and righteousness of their actions in defense of the disintegrating self (shame reaction). Chefetz (2016) includes contempt, dissmell, and disgust within the shame spectrum of emotion, and I see this play out both internally and externally within each pattern. Needless to say, the severity and intractability of chronic shame creates massive turmoil and strain within their most intimate interpersonal relationships.

Research and my clinical experience suggest that what is needed for clients to work through chronic shame is for them to experience solid, stable, caring relationships, including the therapeutic relationship, where they can feel the pluck of the dysregulating shame and share it with another person, have it witnessed, and, against all expectations in their emotional being, have them not be judged or criticized, but witnessed and cared for. This deeply relational process, both within, and outside of therapy, creates opportunities for corrective emotional experiences that begin to unwind the chronic shame, both cognitively for the client, as they begin to develop a fuller relationship with this process that resides in them, and within their neurophysiology. Donald Kalsched (2013) sums this process best: “what has been broken relationally must be repaired relationally. This calls for affectively focused treatment” (p. 13, Italics in original). Processing chronic shame is long term work, and requires nuance and care to weave between the disintegrating, near automatic responses of the shame state, and the need to provide an attuned, caring presence: Over time “the therapist provides an emotional re-education and remediates a developmental void” (Maroda, 2009, p.20). Additionally, it is critical that the intense affect be modulated so that dissociation can be limited and the client can maintain connection to their adult witness within the present moment, as the healing of trauma can only happen in the here and now.

It is my hope that as clinicians, we can attune to this debilitating dynamic in our clients that is often overlooked or misinterpreted, but is actually hiding in plain sight.


Bowlby, J. (1973). Attachment and Loss, Vol. 2: Separation, Anxiety, and Anger. London: Penguin Books.

Chefetz, R. Catastrophic Shame and the Reorganization of Self, retrieved online Nov 4, 2018- http://csar.nyc/catastrophic-shame-and-the-reorganization-of-self/

DeYoung, P. (2015). Understanding and treating chronic shame: A relational/neurobiological approach. New York: Routledge.

Dorahy, M. (2015). Shame and Dissociation in Complex Trauma Disorders Webinar.

Hill, D. (2015). Affect regulation theory: A clinical model. New York: Norton.

Kalsched, D. (2013). Trauma and the Soul: A psycho-spiritual approach to human development and its interruption. New York: Routledge.

Kaufman, G. (1989). The psychology of shame: theory and treatment of shame-based syndromes- 2nd edition. New York: Springer.

Maroda, K. (2009). Less is more: An argument for the judicious use of self-disclosure. In Bloomgarden, A. and Mennuti, R. B., (Eds.) Psychotherapist Revealed: Therapists Speak About Self-Disclosure in Psychotherapy. New York: Routledge, p. 17 – 30.

Schore, A. (2014). The right brain dominant in psychotherapy. Psychotherapy. 51 (3): p. 388-397.

Schore, A. (2017). All our sons: The developmental neurobiology and neuroendocrinology of boys at risk. Infant Mental Health Journal. 38(1): p.15-52

Siegel, D. (2010). Mindsight: The New Science of Personal Transformation. New York. Bantam.