In my work with clients who deal with Body-Focused Repetitive Disorders (BFRDs) I have gradually become convinced that in many individuals shame drives the behavior. BFRDs manifest in compulsive pulling of one’s hair (Trichotillomania), picking at skin and scabs (Excoriation), cutting, carving, biting, and starving (Non-Suicidal Self-Injury NSSI). This shame results from an individual’s unrealistic(even grandiose) expectations of oneself. When expectations are not met perfectly and an individual cannot accept that the expectations were unrealistic in the first place, the system is overwhelmed with fear and anxiety that result in shame.
Shame is different from guilt. Guilt can be explained – you did something wrong. You can confess and be forgiven. Shame – you are wrong. You can only hide and conceal your weakness. The result can be a combination of blurred boundaries, depression and defensive rage.
The cycle is vicious. Unrealistic expectations set up anxiety and fear of failure. When anxiety and fear become overwhelming, self-harm temporarily offers escape from the uncomfortable and finally intolerable state. Engaging in the behavior results in shame and negative self-talk. When efforts to conceal are discovered, and individual defends the secret behavior with narcissistic rage. Once the cycle is complete, the individual resolves to “do better,” “to quit,” and to be the perfect self that set them up for failure in the beginning.
Shame is a challenge for therapists because it causes clients to hide and conceal. Clients will often admit to feelings of aggression-feelings that have power. When you first suggest shameful feelings – clients will deny them and try to escape the discussion.