Anxiety, OCD and shame go hand in hand

As someone who works on anxiety conditions such as phobias and OCD, there is one thing that repeatedly comes up in the work that I do with clients. This is an association with shame and anxiety conditions such as phobias and obsessive-compulsive disorder. Shame feels very personal and sadly keeps things such as phobias, obsessions and compulsions going, with shame integrally tied to these actions. The sense of shame is associated with ‘being different’, ‘losing control’, ‘blushing’, ‘sweating’, ‘doing something that is viewed as 'being weird’ or ‘being watched and scrutinised’.

For many people who have to endure anxiety conditions, the feeling of shame feels like a heavy weight that they carry and which wraps itself around them, as though the tentacles of shame don’t want to let the individual go. People that I have worked with talk about feeling constrained, restricted, suffocated by and smothered by the shame. Their whole relationship with shame is built on the perception that the shame is acting out of control and ‘messing with their lives’. It is as though something is being done to them which is out of their control.

Changing the relationship with shame is one path towards healing anxiety and therefore, bringing up shame as a survival response early on is important in therapy. We all know that shame is physically powerful and associated with words, and is usually also associated with ‘dominant and submissive’ relationships, which become central to the client’s way of responding. Shame acts as a signal of social danger, an alarm signal that says ‘watch out, you are in danger of humiliation or being cast out if not careful’.  

It also leads to autonomic system dysregulation and strong activation of the sympathetic nervous system and the limbic system. These in turn stimulate the ‘fight, flight or freeze’ responses, with the latter placing the individual into a position where they are seen and not heard. In this situation, being heard could have serious consequences against the individual. Shame seeks to close down that ability to be heard and to keep the individual safe from either harm or humiliation.

The reason why shame becomes so integrally linked to anxiety conditions is that it develops cognitive schema that are based on perceptions of self-defectiveness and worthlessness and these both feed into feelings that are strongly associated with anxiety conditions. In other words, they may well get amplified, as individuals find difficulty in doing things in their lives because of high anxiety reactions to things such as travelling, shopping or even going out. 

We must provide some psycho-educational context to clients that we work with who demonstrate strong shame-based reactions in conditions such as anxiety. Exploring events that led to the shame reaction, can provide an entry point into exploring the roots of the anxiety. It is interesting to note, that self-blame in shame serves the purpose of putting the brakes on behaviour that could be punished by others. It serves in some way as a form of active protection and bringing this up in therapy is something that can change the relationship of a client with their shame-based responses. 

Shame and the associated internalised self-criticism therefore provides an individual with a form of self-control, albeit troubling and toxic in the long term. The inner critic that develops from repeated shame-based events is borne from an attempt to control external risk and many people, when asked how old that voice is, point to a young childlike critic, who is still stuck at those points when shame took hold of them. 

Working with shame

Body working, cognitive behavioural therapy and mindfulness are all methods that therapists can use when working with shame. It should also be noted that since shame brings on somatic body responses that also trigger the same pathways as anxiety conditions, using bodywork can have real positive impacts on clients. 

However, for therapists looking to work in this area, the use of curious inquiry and eliciting curiosity within clients can be a strong foundation to build from. Asking clients to be curious about the shame and whether the shame-based response is more of a thought or a feeling are excellent starting points. It is also important for us as therapists to realise how threatening it can be for clients to ‘give up’ and move on from shame.

I always remember the incredible work of Janina Fisher on shame and how she brings ‘parts work’ into play so that clients can give themselves some distance from the shamed parts of them. Her work informs my therapy work in getting the client to connect with the negative beliefs of the parts of him or her that are critical and which feel the shame, and to then get the client to increase their mindful curiosity around how that part adapted to be convinced that the individual was ‘worthless’ or ‘undeserving’. How did this part change the behaviour of the client in their family structure, at school or within their peer group as a way of protecting them?

It is also important to explore how the client survived in the environment in which they grew up and how the critical and shaming part of them served to regulate their fears or anger. In other words, as Janina Fisher says, “If it could not stop the perpetrators, how did it protect the child and support the child”? It is also important to mention that working with parts also increases the mindfulness of a client towards them.

Trauma, shame and the triggering of the ‘fight or flight’ behaviours

We know that there are many mental, physical and emotional consequences of trauma on our clients. Trauma can be found as a significant causal factor for anxiety disorders for shame-based responses and the inability to regulate emotions. This is also why trauma stimulates the ‘fight’ response which in some circumstances is internalised and which fuels the ‘inner critical’ voice.

Traumatic events also stimulate ‘shame’ based responses which play on the need to reduce self-presence and to be unheard and in many ways invisible – much like the flight response.  These two parts remain in a cyclical spiral, strengthening and co-existing with each other, as though each part depended on the other.

However, the key to how impactful therapy can be in reducing shame-based responses is to explore the role that these parts play in the survivability of the client. This means working with the client to acknowledge these parts and to ‘welcome’ them as the ashamed parts, whilst the client extends self-compassion to the parts and to their being as a whole. This, it is hoped, can help the client to change the relationship to these parts and place them on a journey of self-compassion, instead of self-loathing or self-disgust. This is the fundamental engine of the therapy work in shame-based responses within clients.

This is why when I work with clients who have a range of anxiety conditions, I always explore the role of shame within anxiety conditions. It is usually always present, sometimes in many hidden forms and guises. Changing the relationship to it is the start of reducing the impacts of shame and its tentacles on clients.