Middle Phase of Therapy: Working with Self-Criticism and Shame
As John and his therapist empathically co-explore his “short fuse” and the triggers for his anger, although initially unclear to John, it starts to emerge that his anger is reactive and secondary and masks this primary unhealthy painful feeling of shame. John starts to develop awareness of this as he begins to express this underlying feeling as “worthless”, “unlovable”, “not adequate,” and “defective.” John reflects, “I now realize that I see criticism everywhere and I lash out everywhere because I feel inadequate, and then I feel embarrassed after.” In terms of the moment-by-moment case formulation, the therapist and John collaboratively name his core pain as shame and worthlessness, and the anger which often gets triggered as secondary and reactive. This reflects an underlying unhealthy emotion scheme of shame. In EFT, for an emotion scheme to be amenable to change, it needs to be activated and vivified which is an indication to use the two-chair intervention for self-criticism. In this intervention, the client is asked to have one part of their self to express the harsh criticisms or negative statements to activate the other part of self’s painful feelings in response to the criticisms. When primary unhealthy feelings such as shame or fear are activated, these are transformed by accessing alternate healthy emotions, such as sadness at loss, anger at violation, or self-compassion. When accessed, these healthy feelings and their associated needs, help to transform unhealthy feelings. This can either lead to a softening into compassion of the harsh critic and/or a negotiation and integration of the two previously opposing parts of self (Greenberg et al., 1993). Although utilization principles of awareness, expression and reflection are demonstrated here, this process exemplifies the transformation principle of changing emotion with emotion.
To activate John’s emotion scheme of shame, the therapist introduces the two-chair intervention to resolve self-criticism, “…Can you be the critical part of you in this chair. … How do you criticize him?” As the critical part, John states, “Everything you say is a bit off, you have nothing interesting to say, you have no value, you’re worthless, don’t put yourself out there because you will be rejected.” Immediately following this, the critical part begins to get tearful and says, “I feel badly, and it hurts to say this to you, but it feels like everything you say is wrong.” In response to the critical voice, John tearfully expresses, “I just want to run away to escape the pain.” The therapist encourages him to stay with these painful feelings as John experiences and expresses his deep shame and he says tearfully, “It’s such a deep feeling of inadequacy, it really hurts.” While he is experiencing the shame, John is asked what he needs from the critical part, and he expresses poignantly and tearfully, “I need to be accepted unconditionally even if I make mistakes. I need assurance that I am okay, that I am worthwhile.” The therapist validates the significance of this newly emerging need, “Yeah. Mm-hmm. It really touches a place inside as you ask for this, it hurts so much to feel worthless and not accepted, this is just so important, wanting to be accepted unconditionally?” The client tearfully says, “Well yes, I really need this.” The critical part is asked by the therapist, “What’s your response to John who is in so much pain and is asking to be accepted unconditionally?” The critical part start to cry and the therapist asks, “Can you put words to the tears? As the critical part, John expresses sadness and compassion, “I feel sad for him. … I feel sad to see you suffering. I accept you but that’s because I love you.” The emerging sadness and compassion are healthy, and the therapist deepens this by suggesting to the softening critic, “Can you say this to him again? I think that would be very important for him to hear. It sounds like it’s something that he has needed to hear for a long time.” The softening critic responds, “I do love him, and I do accept him, and I don’t want him to suffer as I know how painful it can be, and I don’t want to treat him the way his father did. Hmmm, I thought I was protecting him?” In response to the critic, John states: “It’s okay that you were critical in the past, as long as you love and accept me now. … It’s sad that I have never heard that before.” John is asked to take in this change from the critic and feels a positive shift inside. The therapist reflects on how meaningful and important this is given how harsh the critic has been on him. This is a transformative session as the critic softens and expresses healthy compassion and sadness for John.
At the end of this session, the therapist and John reflect on and make meaning of the origins and function of this self-protective critical part that emerged in his childhood as he was under constant verbal attack from his father; this is part of the utilization principle of reflection. John recalls, “I was afraid to sit at the dinner table because I was criticized for how I ate. And I realize that this self-critical part keeps telling me that I am worthless so I will be careful not to do something where I will be humiliated again.” John reflects that he feels a change inside as he now feels accepted and loved by that part of him as he is beginning to understand that the intention was to protect him. The sequence of changing emotion with emotion is seen in this example: John becomes aware of and attends to the primary unhealthy emotion underlying the secondary reactive anger; the therapist helps activate the primary unhealthy emotion scheme of shame and guides the client to express and deepen it; the heartfelt need related to the painful experience of shame is expressed; the shame is transformed by the therapist’s support of newly emerging transformative primary healthy emotions of compassion and sadness towards self. The therapist validates John’s deep need to feel unconditionally accepted and provides experiential teaching that the need that was asked for is very important as this is connected to John’s core painful feeling of feeling worthless.
To support this in-session change with homework, the therapist provides a rationale and asks John to collaborate on the specifics of the between-session work. In addition, John is guided to try the proposed homework experientially in-session which makes it more conceivable to do on his own as it will allow him to have a lived experience of success:
Therapist: This critical voice has been with you for a long time, and it’s not surprising given what you experienced growing up. In a way, in sounds like you’ve needed this self-protective part because you had to be on guard because of the criticisms you were getting from dad?
John: Yes, if I was hard on myself, then maybe I could be good enough for my dad.
Therapist: That makes so much sense. You’ve made great progress today, giving a voice to that harsh critic that you live with daily and expressing the painful impact that it has had on you. It’s been so painful to live with this critical voice. …
Therapist: What you said you need is so important and is so valid, given that you have felt so worthless or so long.
John: Yes, that feels good to hear.
Therapist: It seems important to identify how the self-protective critical part of you could help you meet your need to feel accepted unconditionally. How could this protective critic that wants to be more compassionate show you that you are accepted, worthwhile, cared for, over the course of the week?
John: I appreciate that it’s been protecting me, but I want to say, ‘dad’s not around anymore, let me make mistakes! No matter how badly I screw up!’
Therapist: Can you actually try to say it directly to that critical part now?
John: Okay. [to critic] I need to be able to make mistakes!
Therapist: [providing validation of need] That is so important. How does the self-protective critical part respond?
John: [as softening critic] You deserve that. You deserve to feel accepted and confident and feel that you’re a worthwhile person. So don’t be afraid to be yourself, whatever that is.
Following this, the therapist guides John to give a concrete example of what contexts he can imagine carrying this out. John is able to express that he would like to feel more accepting in talking to his family and not have to watch every word he says; this allows the task to be more concrete to John’s daily struggle and imaginable. An environment of exploration is fostered, which emphasizes that the goal is not completion or success, but an experiment, ‘try it and see what happens’, and then report back so that it can be discussed and worked on in therapy. Discussing challenges of between-session work can be more productive at times than the successful completion of it. Normalizing that it may not be easy to do the between-session work is especially beneficial to clients who suffer from core shame and who are sensitive to failing. The message to clients is: to try and explore, notice what happens, and discuss it with their therapist. When John returned the following session, without feeling defeated or shameful, he was able to express how the self-protective part had a challenging time being unconditionally accepting; being able to try the exercise outside the session and have a safe environment in-session to talk about this difficulty was very beneficial and shifted the focus of John’s session to exploring the healthy self-protection from dad that the critic had provided.