Shame and Guilt

TLC National Conference

April 24, 2010

Fred Penzel, Ph.D.

Western Suffolk Psychological Services

Huntington, New York

“You cannot prevent the

birds of sorrow from flying

over your head, but you can

prevent them from building

nests in your hair.”

- Chinese proverb

“It's not the hair on your

head that matters.

It's the kind of hair you

have inside.”

- Gary Shandling

TTM is, for a majority of sufferers,

a disorder of shame, silent agony,

inner grief, and isolation.

THE EMOTIONAL EXPERIENCE OF

BFRBs

• Depression

• Shame

• Guilt

• Feelings of defectiveness

• Secrecy

• Isolation

• Loneliness

• Anxiety

“On the one hand, I knew I was

highly intelligent and functional,

externally looking good; on the

other hand, I had no control over

the inner battle with my

compulsion, so I believed I was

weak and must be a defective

human being.”

- Christina Pearson

Trichotillomaniac ?

Shame is an emotion of self-blame. It is a

self-conscious emotion with a strong

component being the desire to hide and

escape. Repeated shaming experiences

can wear down an individual’s self-image.

Defining Shame

Tangney and Dearing, 2003

Defining Shame (cont.)

A painful emotion resulting from

a sense of inadequacy,

unworthiness, embarrassment,

or disgrace.

Defining Guilt

• Guilt is a cognitive or an emotional

experience.

• It occurs when a person feels

remorse and a sense of self-blame

upon realizing or believing — accurately

or not — that they are responsible for an

inadequacy or wrongdoing.

• It also includes the belief that they bear

sole responsibility for that violation.

Hair and Self-Image

A survey of 120 Yale undergraduate

students who were not specifically hair-

pullers found that those who rated their

hair as looking badly on the day of the

survey showed a significantly poorer

sense of their own capabilities and were

more likely to use negative words to

describe themselves.

(LaFrance,

2000)

Hair and Self-Image (cont.)

A 2007 survey of r 1,022 respondents sponsored by the Hair Sciences Center of Colorado revealed that:

• 52 percent of respondents believed that men and women who have what is perceived as "good hair" get better jobs.

• 53 percent said men/women with good hair had more attractive partners.

• 66 percent said they thought that men with a full head of hair were more successful. Men losing their hair ranked the least successful, even more so than those who were bald.

• 46 percent said that men with "good hair" are smarter than those who are balding or bald.

For some TTM sufferers, their poor self-

image and feelings of shame and

embarrassment require much more of an

intervention than the hair-pulling, itself.

Stigmatization

Stigma – The definition

• A mark made by a pointed instrument or a branding iron.

• A mark of disgrace or infamy, a sign of severe censure or condemnation regarded as impressed on a person

or thing. It was frequently used to mark slaves and convicts.

Emotional Responses to TTM

Low self-esteem 84

Diminished sense of attractiveness 82

Shame and embarrassment 80

Problems with tension or anxiety 68

Depression or mood problems 66

(Mansueto et al, 1990)

%

Activities Avoided by TTM Sufferers

%

Haircuts 87

Swimming 62

Being outside in the wind 42

Sports 35

Sexual Intimacy 35

Lighted areas 25

Public activities 22

(Stemberger et al, 2000)

Life Impairment Among Adult TTM Sufferers

(TIP – A Study)

• Avoided social events 40

• Avoided group activities 36

• Interfered with work on a daily basis 23

• Avoided going on vacation 20

%

(N = 1697) (Franklin et al, 2006)

Life Impairment Among Child TTM

Sufferers (TIP – C Study)

Based on parent report:

• 55.6% (n = 74) reported that their child avoided social events as a direct result of pulling.

Based on child report:

• 54.9% (n = 67) of the child sample reported that TTM made it more difficult to study

• 36.1% (n = 44) reported that their ability to do well academically was impaired as a direct result of pulling.

Special Shame and Guilt Problems

For Children With BFRBs

• Teasing by classmates in school

• Teasing by siblings

• Punitive teachers

• Well-meaning teachers trying to be therapists

• Family conflict and bad feelings resulting from parents’ attempts at control

Typical Family Contributions to

Shame and Guilt

• Shaming and insulting

• Yelling at the sufferer

• Discussing the problem in front of others or in public

• Attempts to control pulling by calling attention to the behavior, sometimes even in public or in front of friends and relatives

• Punishing for hair loss or when observed pulling

• Exclusion from family activities (meals, social events, trips, etc.)

“It wouldn’t be as bad if it was

something that just happened to

me, like alopecia, but how do you

tell someone you did this to

yourself?”

- One of my TTM patients

Excuses patients have been used to

explain their hair loss to others:

• Alopecia

• Hormonal problems/menopause

• Male pattern baldness

• Accidentally rubbed it off

• Burned off in an accident

• Chemotherapy for cancer

THE MORAL MODEL OF

PSYCHIATRIC DISORDERS

People who cannot seem to control their

own behaviors are clearly weaker than

others and lacking in character, and

therefore have no one but themselves to

blame for the problems they have

obviously brought upon themselves, as

well as their continuation.

So how do you

destigmatize yourself?

Why doesn’t everyone with TTM

feel stigmatized?

Question:

Olympic Silver Medal winner Kristy Kowal and

Gold Medal winner Staciana Stitts

“Men are disturbed not by

things, but by the view which

they take of them.”

- Epictetus (55 – 135 A.D.)

COGNITIVE THERAPY

Based upon the theory that many emotional

disturbances are caused not by other people’s actions

or by external situations, but rather by the illogical or

extreme ways we view and interpret these things.

CT attempts to treat disturbed emotions by teaching

people how to spot errors in their thinking and how to

have emotions that are more moderate and

appropriate to whatever situations occur. This leads to

better coping and healthier emotions.

CT approaches the treatment of disturbed

emotions by teaching people skills in how to:

• learn to better listen to themselves and spot errors in

their own thinking

• vigorously challenge these extreme and erroneous

beliefs and see their flaws

• correct them and through repeated practice, replace

them with more moderate, logical, and provable ideas

and better self-talk

Some Important Points About

Cognitive Therapy

• It deals with problems in the here and now

• It gets you to accept personal responsibility for your emotions and behavior

• It discourages you from blaming problems on other people or things

• It encourages you to change yourself, rather than other people or situations that will never change

• It encourages unconditional self-acceptance

Common Irrational Beliefs Seen Among

BFRB Sufferers

• If I cannot control my behavior, I am a weak and worthless reject.

• I must make perfect progress in treatment, and if I cannot, and end up having slips, I am a weak and worthless person, and will never improve.

• Because I have damaged my own appearance, I must be defective and crazy.

• Because I have not been able to control my behavior in the past, I will not be able to do so in the future.

Common Irrational Beliefs Seen Among

BFRB Sufferers (cont.)

• Because I am worthless and defective, I do not deserve to recover.

• As a result of my defective appearance, I will always be undesirable, and no one will ever want to be with me.

• If my friends/loved ones knew about my behavior, they would think I was crazy and reject me.

• I hate my behavior and cannot help but get upset and depressed whenever I have to face it.

Common Irrational Beliefs Seen Among

BFRB Sufferers (cont.)

• Getting control of this behavior is simply too hard. I will

never recover.

• It’s not fair that I have this. It shouldn’t be. Life should

have treated me better.

IBs Commonly Seen in BFRB Sufferers

in Treatment

• Recovering should not be hard for me.

• Getting recovered should not take long.

• I should get well perfectly and without slips or setbacks of any kind. If I do have them, it will prove I simply cannot recover.

• I must have everyone’s support and understanding if I am to recover.

• I cannot simply settle for recovery. I must be absolutely cured.

The Structure of a Disturbance

An event happens

You tell yourself something extreme and

illogical about it

You react with extreme emotions

and behaviors

How To Relieve A Disturbance

Dispute and question each belief, seeking evidence that

will either support or debunk it

Find new beliefs to replace the ones that cannot be

supported by the facts. These new beliefs will most

likely be much less extreme and more logical

See if you can predict what the consequences would be if

you had used your new beliefs to begin with

The ABCs of Disputing and Changing

Irrational Beliefs

1. Briefly describe the Activating Event (how it all

started)

2. State the emotional and behavioral Consequences that followed the Activating Event

3. Identify the Beliefs that came between the A and the C(what you told yourself about w. Briefly describe the Activating Event (how it all started)

The ABCs of Disputing and Changing

Irrational Beliefs (cont.)

4. State the emotional and behavioral Consequences that followed the Activating Event

5. Identify the Beliefs that happened)

6. Dispute and question each belief to see if it is logical and correct

7. Restate, moderate, and replace those of your original Beliefs which could not logically stand up to being disputed

8. Predict what the Effect of more logical and realistic thinking would be on your original consequences

(A) Activating Event:

I have pulled out a lot of my hair, and

have many bald and thin spots. It

doesn’t look very good at all.

(C) Consequences (emotional and

behavioral):

I feel angry at myself, and am depressed a

lot of the time. I avoid dating and social

contacts.

(B¹) Beliefs:

Because I have pulled out a lot of my

hair, it proves I am a crazy, weak,

defective, and worthless person that

no one will ever find attractive.

(D) Disputation:

1. How does pulling out my hair prove that I am crazy?

It doesn’t. I am a normal person in all other respects,

and am not having delusions or hallucinations. My

behavior may seem crazy to those who do not

understand it, but that doesn’t make me crazy. I can

conduct other areas of my life in a rational manner.

2. Where is the evidence that it makes me defective, weak

and worthless as a human being?

There is none. Hair-pulling is just one aspect of the

many thousands of things that make up the totality of

who I am. I am more than the sum total of the hairs on

my body. It does not totally define me as a person and

is not my complete identity. Also, it is something I can

recover from, so how can something so changeable be

used to measure me?

3. Is there really any proof that no one will

ever find me attractive?

While I may not look my best at the moment,

there is no proof that no one will ever find me

attractive. No one can predict the future, and I

can do my best to recover. I will do what I can

for the moment to improve things cosmetically,

but attractiveness is not simply external. It also

has much to do with the person I am and the

way I live my life.

(B²) Restate and Moderate the Illogical beliefs:

1. I really don’t like the fact that I pull my hair, and I totally

dislike the effect it has on my appearance, but I know that apart

from this problem, I am in all other respects a normal person. It

is a behavior that I do, but it is not my identity as a human being

and I can see myself beyond my symptoms.

2. Even if I don’t look the way I would like at present, it doesn’t

mean that I cannot keep working to make things better in the

future.

3. I cannot completely control who does or does not find me

attractive, nor can I predict that I will not improve my appearance

in the future. I do not have to choose to live as a social recluse

and can still spend time with friends and even date if I wish to . If

someone is unable to appreciate me as a person, it is probably

someone I wouldn’t choose to be with anyway.

(E) Predict the effect of new beliefs on original

emotional and behavioral consequences:

I would not waste time feeling angry at myself, and

would stop making myself depressed over ideas that

do not make any sense.

I could stop letting society dictate to me how I should

feel about myself, accept myself as the complex

being I am, and stop reducing myself to merely one

characteristic.

I could get out more, and perhaps even date if I felt like

it. Who knows – I might just find someone who

understands TTM and appreciates me and accepts

me as I am.

Getting

recovered is

not just

about

getting your

hair back.

It’s really about learning to

accept yourself unconditionally.

What is Unconditional Self-Acceptance?

1. Self-acceptance encourages you to think of yourself as an ordinary, imperfect, fallible human being, who because of this, is the equal of all other human beings.

2. It differs from self-esteem by allowing you to accept yourself without any external props or conditions. You can be yourself without having to prove yourself.

3. You accept yourself even with your problems, and then, because it would be to your advantage, work persistently and relentlessly to solve them.

What is Unconditional Self-Acceptance?

(cont.)

4. It allows you to fully accept yourself without needing

justification, and teaches you to accept yourself in spite

of your errors and imperfections.

5. Unlike the pursuit of self-esteem, you are protected

emotionally if others don't validate you, or if you make a

mistake. Once you begin to pass judgment on yourself,

your emotional health is at risk.

Rating Yourself As A Person Is A Trap

• Self-evaluation leads to feelings of unworthiness and deficiency. This then leads to depression, anxiety, and avoidance of change. The best thing is for us to stop evaluating ourselves altogether.

• Giving yourself a total self-rating is an overgeneralization and impossible to do accurately. You are too complex, and consist of literally millions of acts, deeds, and traits during your lifetime.

• Even if you could accurately know and rate all your millions of acts and characteristics, how could you get an overall rating of the 'you' who performs them?

Rating Yourself As A Person Is A Trap (cont.)

• The trap in rating yourself, is that you can only consistently feel good if you are truly perfect in the present and future, and this is unlikely.

• Rating your performances and comparing them to those of others will almost inevitably result in anxiety when you may do any important thing badly, depression when you do behave poorly, angry when others out-perform you, and self-pity when conditions interfere with your doing as well as you think you should.

• If you still insist on rating your self, try viewing yourself as being valuable or worthwhile just because you are human, because you are alive, and because you exist.

Rating Yourself As A Person Is A Trap (cont.)

• What you can legitimately say is, “I am acceptable

because I exist, and not simply because I do something

special.”

• The one thing you can legitimately rate, it is your acts,

deeds, or behaviors. You can legitimately rate these in

terms of how well they help you to achieve your goals.

• Just remember that doing well doesn’t give you an

overall good rating as a human being, any more than

doing badly makes you totally bad.

True beauty consists of

purity of heart.

- Mohandas Gandhi

Dr. Penzel can be reached at

Western Suffolk

Psychological Services at:

www.wsps.info