Guilt and shame

I've always thought of guilt and shame as two sides of the same coin.  In theory, when you do something wrong you feel guilty; when people find out about it, you feel ashamed.  Thus, one can feel guilty about something he's done even when no one else knows about it; he only feels ashamed, however, once his actions are discovered and his guilt is brought to light. 

In my mind, shame was a mixture of embarrassment and guilt brought about by having one's misdeeds made public.  I saw guilt, on the other hand, as a moral compass of sorts, one that alerts you when you've strayed too far off course.  Apparently, though, I've had it all wrong.  It turns out that people who study this type of thing think about guilt and shame quite differently.  To feel guilty is to condemn specific actions, i.e., you feel guilty about something you've done.  When, in contrast, a person feels shame he condemns himself.  In other words, I feel guilty about what I've done; I feel ashamed of who I am.

I have no problem with this perspective; it makes a certain amount of sense.  Who am I to argue with the experts?  Moving on...

Guilt is often uncomfortable and unpleasant but it also serves an important social function in that in promotes cooperation and adherence to group norms.  (Consider this: the inability to experience guilt and remorse is a characteristic of most psychopaths).  Studies show that guilt tends to motivate conciliatory behaviors and efforts at restitution.  Because it serves as an impetus for corrective action when social norms are violated, guilt facilitates the restoraction of peace and cooperation, thus enabling individuals to live and work together in communities.

Shame, on the other hand, yields very little in the way of benefits (at least according to the experts).  Whereas guilt often motivates reparative actions, shame tends to induce behaviors that are self destructive.  With guilt, the focus is on one's actions and their consequences to other people.  Shame, however, is a self-focused emotion characterized by a a sense of unworthiness and self-directed contempt.  Shame is associated with negative attributions towards oneself and is frequently accompanied by low self-esteem. 

Over time, shame leads to self loathing.  Pause for a moment: have you ever known someone who hated himself?  Think about what this person was like...

Probably very sensitive to any negative feedback.  People who carry a lot of shame tend to be very defensive.  You see, the job of the human "ego" (or sense of self, subconscious, identity, self concept, or whatever you want to call it) is to protect itself and to maintain its integrity.  Shame leads to self loathing; this poses a serious threat to the "ego."  The "ego" of someone who hates himself is under constant attack from the inside; an attack from the outside would be crippling.  So it builds up a network of defenses to protect it.  Thus the shame filled individual blames others for his mistakes and refuses to accept responsibility for his actions. We think he's just being an asshole.  The truth is, his fragile ego cannot withstand the blow of acknowledging he did something wrong; he can't even admit it to himself.  And obviously if a person can't admit he did something wrong, he certainly can't come to forgive himself...

Which is what I plan to talk about next week - self-forgiveness.

A personal story...

Last week I mentioned that my insurance company no longer wants to pay for the medication I've been taking for the past decade.  I'm in the process of appealing this.  It has been extremely stressful.  I sought help from my doctor, who said there was nothing she could do to help, and from the state insurance commissioner, who told me his office won't get involved until after the appeal is completed.  I requested additional information from the insurance company; in response, I got a letter stating that I could submit a request for more information.  After a week of this, I realized that I was going to have to figure out the whole appeal thing by myself; nobody was going to help me.  So I got to work.

The first thing I did was write a brief personal statement about how the medication has helped me and what the consequences will be if I can no longer take it.  This was fairly easy and I finished it quickly.  The next part was a lot harder.  My task was to find empirical evidence demonstrating that the medication at the dose I'm taking is effective.  I worked on it all of last week.  I finally finished it on Friday and faxed it to the insurance company.  Now I just have to wait.

Because I've been so consumed with this whole insurance things, I haven't had much time to think about blogging.  Still, I like to be consistent in posting something at least once a week.  So today I though I'd share the personal statement I sent the insurance company.  It's part of my story and it's a part I've never talked about on the blog.  Anyway, here it is:

My name is Melody.  I have narcolepsy.  My symptoms started during my senior year of high school.  I began falling asleep in my classes.  I remember one occasion when I fell asleep during a test.  When I woke up, everyone was passing their tests in.  I looked down at my own paper, which was completely blank.  I realized with dread that I’d slept through the entire thing.  Needless to say, I failed that test. 

I started college the following year.  I struggled to stay awake during lectures.  In between classes, I’d crawl into the back seat of my car and sleep.  One morning, I fell asleep while I was driving to school and caused a car accident.  I decided then that I needed to see a doctor; something was seriously wrong.

I related my concerns to my psychiatrist, who was already treating me for depression.  Over the next two years, my doctor prescribed a number of medications at different doses in an effort to control my symptoms.  I tried methylphenidate, dextroamphetamine, and mixed amphetamine and dextroamphetamine.  None of these medications successfully alleviated my symptoms.  Finally, my psychiatrist recommended I see a neurologist.

The neurologist ordered an overnight sleep study and a daytime MSLT.  The results were suggestive of narcolepsy.  Later, he ordered blood work to test for specific human leukocyte antigens (HLA) strongly associated with narcolepsy (I tested positive for these antigens).  After all the tests were completed, the neurologist diagnosed me with narcolepsy; I was 21 years old. 

Having a diagnosis didn’t solve the problem.  The neurologist initially prescribed modafinil.  Still, I kept falling asleep: at school, at work, and while driving.  After trying modafinil, the neurologist prescribed Adderall XR.  He started me at 30 mg. first thing in the morning and 15 mg. a few hours later.  This controlled my symptoms until about 2:00 in the afternoon.  Unfortunately, I had several classes later in the day (I was still in college); I couldn’t simply go home and crash at 2:00 PM.  My neurologist gradually increased the medication dosage until we arrived at a dose that successfully controlled my symptoms throughout the entire day: Adderall XR, 30 mg., three times per day. 

I have been on Adderall XR at this dose ever since.  I have been able to live an almost normal life.  I graduated college and went on to graduate school.  I have a successful career as an outpatient psychotherapist.  Never once have I fallen asleep during a patient’s session.  I can drive the forty five minutes to and from work without fear of falling asleep behind the wheel.  I can go to the gym after work, come home, and eat dinner with my husband.  I can wake up the next morning and do it all again.  I can function.  I can live.

And now all of that is in jeopardy.  My health insurance company changes its rules and decides it will only pay for Adderall XR 30 mg. once a day.  This is one third of the dose I’ve been taking for the past nine years.  They say I can continue taking Adderall XR 30 mg. three times per day, but I’ll have to pay for what they don’t cover.  It will cost me around $300 a month.  I simply cannot afford it.

Happy New Year, from your friendly health insurance provider

Thirteen days into the new year and already I've spent a disproportional amount of 2013 figuring out how to appeal my insurance provider's decision to deny coverage for the medication I've been taking for the past nine years.  I received a letter notifying me of their decision last week.  My stomach has been in knots ever since and I've been plagued by incessant dread.and a sense of impending doom. 

This is not just me being melodramatic.  There is a lot at stake here and the potential consequences for me are huge.  The medication will end up costing me about $325 a month if I can't convince the insurance to continue paying for it.  Yet not taking the medication isn't an option either, unless my doctor can come up with something that works just as well.  I don't hold out a lot of hope for that though; we tried probably five different medications before trying the medication I take now.  None of the other ones worked.  

So I find myself in a situation that seems hopeless to me.  It appears that the only way to prevent a significant setback in my life - probably a financial one, since not taking medication would pose a serious risk to my health - is to convince the insurance company to pay for my medication.  I am, of course, going to focus all of my energy on building a persuasive argument.  My interactions thus far with the insurance company, however, have not been encouraging.  I spent the whole of last week trying to get information from them.  They say I should receive something in the mail, but I've yet to get anything.

Even my doctor seems to have abandoned me.  I called her office last Monday morning...and Tuesday and Wednesday and twice on Thursday...and nobody ever called me back, not even when I said it was urgent.  On Friday, I went to the office in person to find out what was going on.  There, the staff members at the front desk were extremely rude.  I was told that my doctor can't help me and that it's my responsibility to deal with the insurance company...As a [mental] health professional myself, I know that the doctor does, in fact, have if not a legal then an ethical obligation to help me with this situation.  The insurance company wants to know why the doctor considers my medication to be "medically necessary."  Obviously, the doctor is the best person to explain this.

I left my doctor's office on Friday feeling depressed and defeated.  I took the weekend off from worrying, but I'll be back at it again tomorrow.  I've scheduled an appointment with my doctor; it will no longer be possible for her to ignore me.  I had hoped she would be an advocate for me; I feel like I could really use one right about now.

The things that helped me most

About a year ago, my little sister was going through a difficult period in her life.  My heart ached for her, both because I hated to see her hurting and because I knew how she felt; I went through a very similar period in my own life several years ago.  I did all the normal things that sisters do in times like these - mostly just being there to talk and to listen - but I felt there should be something more I could do to help.  Ultimately, I decided the best way to help was to share with my sister what helped me in my own struggle.  To this end, I wrote her a letter.

I realize that just because something helped me doesn't mean it will help someone else.  But it might.  I'm not going to share the more personal tidbits of the letter I gave my sister, but I do want to share the strategies that helped me get through some pretty dark times.  So here goes:

A visual journal: I poured my heart and soul into visual journaling for about a year.  The art itself was at times mediocre; at times it was quite shitty.  The process of creating the art…it was amazing.  It was like I was literally pouring my emotions out.  They made so much more sense when I could see them on the outside (and not just inside of me, where they usually hang out).  I found a good article that explains the whole process.  Check it out:

http://www.psychologytoday.com/blog/the-healing-arts/201006/cool-art-therapy-intervention-4-visual-journaling

Looking for patterns:  People tend to act out their unresolved psychological or emotional conflicts.  Look for patterns.  Look back over your life and identify any behavior or set of behaviors that have repeated themselves over and over again.  For me, this was repeatedly falling in love with emotionally unavailable, commitment phobic men.  There were all sorts of reasons for this, not all of which I have identified even now.  Still, it’s important to see the pattern and to think about what might be driving it. 

Identifying your emotional needs and not expecting one person to meet them all: I read this book once that completely blew my mind.  It was called “How to be an Adult in Relationships” by David Richo.  He says that we should not expect a partner to meet more than 25% of our emotional needs.  The rest we have to get met in other people (friends, family, coworkers, etc.) or activities (art, music, relaxation, etc.).  We also have to learn to meet some of them ourselves.  Briefly, the “5 A’s” are: attention, acceptance, appreciation, affection, and allowing (yourself and others to be as they are).  You should really read this book.

Pay attention to how you talk to yourself: Everybody talks to themselves, either out loud or in their heads.  When I first started working out, I remember “motivating” myself to push harder by telling myself, “Move your fat ass” or “Keep going bitch!”  I used to think to myself that maybe I was unlovable.  (I later learned that there is no such thing as unlovable, but more about that later).  Just thinking these things made me feel like shit.  Yet, I still didn’t understand why I didn’t like myself.  Here’s the deal: you have to treat yourself like you treat people you like.  You don’t go around calling your friends bitches or worthless and you shouldn’t do it to yourself.  If you want to learn to love yourself then the first thing you have to do is to be nice to yourself.  Don’t put yourself down.  (Tell yourself to shut up when you do put yourself down). 

Acceptance: Accept yourself as you are without wishing to be something or someone else.  That doesn’t mean that there aren’t things you want to work on or goals you want to achieve.  It’s always good to work to become better; just don’t do it because you think you aren’t good enough as you are.  Accepting yourself as you are is not something you can just do once and be done with it.  (I wish it were that easy).  Self acceptance is something you have to do over and over again, every time you notice that you’re unhappy with how you are. The irony of self-acceptance is this: it is not until you accept yourself as you are that you are able to change.  If you always put off being happy with who you are – I’ll be happy when I get a good job, I’ll be happy when I get my own place, etc. – then you will always end up being disappointed. Acceptance – contentment – is something that happens right now, in the moment, or not at all. 

Self-compassion: Think about how you would feel if you see someone you love suffering.  You feel for that person and offer them love, warmth, and kindness.  You don’t judge him or say to him, “See, that’s what you get,” even if his suffering is the result of his own bad decisions.  “Everyone makes mistakes,” you tell him.  “Don’t beat yourself up.  You’re only human.”  You might go out of your way to check up on your loved one or to do something nice for him because you know he’s having a hard time. This is compassion.  Most of us have no problem offering compassion to other people.  Yet when faced with our own suffering, we tend to respond in ways that are decidedly un-compassionate. Take time to acknowledge when you are hurting; don’t try to ignore it or “suck it up” in hopes that it will eventually go away.  Recognize that you are going through a difficult time and think of ways to comfort yourself.  Give yourself extra attention.  Instead of judging or criticizing yourself, give yourself permission to be human.  Making a mistake or going through a hard time is part of being human.  You don’t have to beat yourself up for it.  Some people think, “If I’m not hard on myself then I won’t learn from my mistakes.”  This is not true.  Putting yourself down doesn’t teach you a lesson, it just makes you feel like shit.  It’s not helpful.

Core beliefs: These are the things our problems are made of.  Core beliefs typically operate on a subconscious level, so most of us are not really aware of them.  There is so much going on in our external environment at any given moment that there is no way our brain could take everything in.  Our brains use our core beliefs as filters.  Information that is consistent with what we believe about ourselves, other people, and the world is deemed important and is allowed into our conscious awareness.  Information that doesn’t fit with our core beliefs is deemed unimportant and is filtered out without ever reaching our conscious awareness.  In this way, our core beliefs influence how we perceive the world around us.

People need core beliefs; we can’t function effectively without them.  Sometimes, though, people have beliefs that are extreme and distorted.  This inevitably creates problems.  The core belief that created so many problems for me was, “I am unlovable.” 

Most people suffering with depression have at least one or two unrealistic core beliefs that are contributing to their negative emotions.  It is important to identify yours so that you can work to change them.

I hope this helps!