Humiliation and Its Impact On Our Patients and On Us

Perhaps you’ve read the book or seen the movie Dead Man Walking? Recently, I had the opportunity to view the opera version presented by the Des Moines Metro Opera.

As the tension grows, the audience waits for a confession by death row inmate Joseph De Rocher. As a psychiatrist, I too waited for revelations on his motivation. At least in the opera version of this story, De Rocher’s confession to Sister Helen, who became his spiritual adviser, is that he indeed raped a teenager, stabbed her to death, and shot her boyfriend dead.

Besides being “loaded” on street drugs, he experienced a “come-on” by a beautiful woman at a bar. When he suggested she meet him at the same site where the crime was later committed, she laughed at him and walked away. He conveyed feeling increasing rage and sexual desire after the rejection. He felt humiliated.

De Rocher’s story evoked many professional and personal memories that I seldom think about anymore. I remembered a case I had in our public clinic near the end of my clinical career. A male patient was accused of sexually abusing a child: he shared over and over with me that he would commit suicide if he was convicted. He was on an outpatient commitment, which didn’t seem safe enough to me. I recommended inpatient treatment, but he refused and didn’t meet our local legal requirements for commitment. Sure enough, I found out later that he was convicted and then committed suicide.

Certainly, like all people, I have felt humiliated at times in my personal life. The worst such experience may have been at the most vulnerable time for the development of personal identity-adolescence. You may note some sort of connection to De Rocher’s case.

The experience occurred at my high school junior prom. While my date and I were lying on a beach blanket, she told me she was having an intimate relationship with one of my “best friends.” Their relationship soon went as public as it possibly could in those pre-Internet days. I felt powerless and felt the urge to strike my former friend physically. Fortunately, my impulse was averted and my self-esteem partially restored by other friends who rallied around me.[[{"type":"media","view_mode":"media_crop","fid":"26626","attributes":{"alt":"humiliation vs shame","class":"media-image","id":"media_crop_6211924501773","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2507","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","title":" ","typeof":"foaf:Image"}}]]

That experience also made me more curious about relationships, and helped to consolidate my growing interest in becoming a psychiatrist. Even so, the subject of humiliation was not much of a focus of my later psychiatric education. The closest we came to focusing on this issue was during the self-psychology taught during my residency training by its originator, Heinz Kohut. Although not clearly identified as humiliation in some published transcripts of these seminars,¹ narcissistic injuries could be caused by humiliation, with the possible outcome of narcissistic rage in the narcissistically vulnerable. Other affective states-sadness, depression, anxiety, fear, and anger-were covered much more extensively than shame and humiliation.

Ironically, though, an instructor of psychoanalysis seemed to use humiliation as a teaching tool, but not as a subject of study. If you didn’t come close to answering this teacher’s pointed questions, you were publicly belittled as a would-be psychiatrist. Fortunately, I escaped most of the usual humiliating experiences that medical students of the time often encountered that would have left me vulnerable to such barbs.

I wondered if I was more ignorant than the general psychiatrist about humiliation. Risking a bit of humiliation to answer that question, I made an inquiry to several professional list-serves about what members thought and knew about humiliation.

The responses were gratifying, if not surprisingly numerous, especially from members of the Group for the Advancement of Psychiatry (GAP). Comments ranged from Talmudic commentary to a recent article in Vanity Fair by Monica Lewinsky. Many commented that the topic needed much more study and a more comprehensive integration.

I found a book that focused exclusively on humiliation² and found some surprising information, but some major questions called for more answers. Was it possible that although psychiatry had no trouble discussing sex and money, humiliation was a kind of unrecognized taboo subject?

Despite the fact that we all experience humiliation and that the term is used so extensively, its definition is far from self-evident. The uncertainty and confusion seems to reside in how or whether humiliation differs from shame. Often, the terms are used interchangeably.

In one school of thought, shame and humiliation are conceived to be on a continuum. That view is most expensively presented in the Affect Theory of the psychologist Silvan Tompkins.⁴ He posited 9 biologically based affects, which may be shared in some part with animals. These 9 affects consisted of pairs, each of a high/low intensity. Shame/humiliation was said to be a late evolving negative affect, with shame being less intense.

Others emphasize the important distinctions between shame and humiliation. In his discussion of the differences, psychiatrist Aaron Lazare⁵ makes numerous points. In essence, and in line with the definitions given in my trusty old Webster's Collegiate Dictionary, shame should be considered a painful feeling when one does not believe they have lived up to a sense of social personal honor and/or morality.

Humiliation is also upsetting-perhaps even the most painful of all human emotions. It involves a general sense of low self-esteem. Humiliation is not so much precipitated by a personal failure, but by the actions, intended or not, and usually public, of others with more power at the time. The power of the other can be physical and/or psychological. The usual dynamic then includes a humiliator, a victim, and witness(es). It is the experience of being “put down” for who one is, rather than what one does as in the case of shame. At its most intense, it has been described as “soul murder.”⁶

Shame at its worse has been described more as an inner torment, a sickness of the soul. Shame, though not humiliation, is often connected to guilt. Shame is more connected to the personal negative evaluation of others, whereas guilt involves personal behavior being negatively valued by oneself.

Whether there are quantitative and/or qualitative differences between shame and humiliation, there can also be differences across cultures and gender. Most worrisome for society, though, is that while people often withdraw with shame, the propensity to react sooner or later with anger-and sometimes violence-is much more likely with humiliation. Worse yet is when a vicious cycle of humiliation and retaliation is established.

Humiliation, like shame, occurs in individuals, but it can also be shared in groups. Personal identity and self-worth can be related to the success of a gang, sports team, or country.

What are the psychological ramifications of humiliation?I‘ve put up with more humiliation than I care to remember.–Blues guitarist B.B. King

To some extent, humiliation is part and parcel of the human experience. Some make the case that minor experiences can be psychologically beneficial. Teachers may feel that humiliation enhances learning. Parents may feel it can reduce undesirable behavior. Bosses use it in the workplace.

However, limited research indicates the more likely destructiveness of humiliation, at least when it is not desired. With advanced neuropsychology techniques, one study indicated that feeling humiliated was more negative than feeling angry, and more intense than happiness induction.⁷ Interestingly enough, humiliation feels worse when it comes from a previously admired source.

Although there are no official diagnostic disorders centering on humiliation (eg, “humiliation disorder”), humiliation seemingly has a role in some DSM-5 disorders. Besides its association with narcissistic personality disorders, it is mentioned in the diagnostic criteria for social anxiety. It is discussed as a desired state in sexual masochism. Though not explicitly mentioned, humiliation would seem to be a concomitant reaction to some traumatic experiences, and thereby PTSD. When one is already depressed, it can intensify the depression. One can try to bury the feeling by various kinds of substance abuse.

At its extreme, the repercussions of intense humiliation can be devastating-precipitating both suicide and homicide. Recall the case of Tyler Clementi, a freshman at Rutgers who jumped off the George Washington Bridge after he discovered he had been videotaped in an intimate encounter with another male. Regarding homicide, most obvious was the humiliation that Elliott Rodgers reported receiving by women, whom he blamed for his violent shooting spree not long ago in the Santa Barbara area. Humiliation seems to be prominent in many other recent mass murders. Similarly, sociological studies indicate that humiliation can play an important role in many international conflicts, ranging from Hitler and Nazi Germany to the Middle East.8 Here, genocide may be the equivalent goal of homicide.

Is this the age of humiliation?Thanks to the Drudge Report, I was possibly the first person whose global humiliation was driven by the Internet.–Monica Lewinsky

The often necessary exploration of childhood humiliation may be a prominent reason why patients in therapy may feel worse before they feel better. They should be warned of such.
The important challenge for mental health professionals to help understand and reduce humiliation. In all clinical encounters, clinicians have to be ultra-sensitive and empathic for what may seem humiliating to patients.
At its extreme, the repercussions of intense humiliation can be devastating-precipitating both suicide and homicide.
To some extent, humiliation is part and parcel of the human experience. Some make the case that minor experiences can be psychologically beneficial.

Some may say that this is the Age of the Self, given the popularity of “selfies” and Facebook profiles. Modern technology makes humiliation easier. One can comment anonymously. YouTube videos spark international outrage, as evidenced by the violent protests that followed a preview of the movie Innocence of Muslims, which portrayed degrading images of Islamic culture.

Sometimes, as in Internet pornography or reality TV, humiliation is portrayed as almost desirable. Being desired and enjoyed, however, does not make these experiences necessarily psychologically healthy.

How can we reduce humiliation?I swore never to be silent whenever and wherever human beings endure suffering and humiliation.–Elie Wiesel

Humiliation could have been at the heart of the landmark Tarasoff case-the court decision that required clinicians to warn and protect intended victims of their patients. In 1969, Tatiana Tarasoff was murdered by Prosenjit Poddar, who had been receiving mental health care at the University of California. After Poddar told his therapist that he felt rejected and rebuked by Tarasoff and wanted to kill her, the therapist informed the campus police without telling Poddar of that possibility. After a brief questioning, the police released him. Tarasoff was never warned and was killed shortly thereafter. A review of what is known about the case suggests that Poddar likely felt humiliated, not only by Tarasoff, but by his therapist’s contacting the police.

This case indicates the important challenge for mental health professionals to help patients understand and reduce humiliation. In all clinical encounters, clinicians have to be ultra-sensitive and empathic for what may seem humiliating to patients. As a simple example, adults should never be addressed by their first name unless they request this.

Indeed, the very fact that one needs mental health care can feel humiliating. In contrast to physical illness, mental illness often feels like it alters one’s very identity and worthiness.

When the power differential extends to attempts at forced outpatient and inpatient treatment, a patient’s sense of humiliation will likely increase. The repercussions can cause patients to leave treatment suddenly, but also they may be a driving force in the anti-psychiatry movement. In political negotiations, the same dynamic may be present.

In Dead Man Walking, Sister Helen offers a therapeutic model for addressing humiliation. She is patient, affirming, and respectful, and she conveys compassionate love, while doing her own self-searching. The often necessary exploration of childhood humiliation may be a prominent reason that patients in therapy may feel worse before they feel better. They should be warned of such.

Psychiatrists need to appreciate the impact of humiliation in our own field. We tend to be perfectionists, so public failure can be humiliating. Being sued (whether legitimately or not), is humiliating. We are often said not to be real doctors, or that we are doctors afraid of blood. We have lost leadership in many clinical settings. DSM-5 was met with more disparagement than fanfare.

There is no anti-humiliation medication
So what are essential antidotes to humiliation? Some key points:

• increase public respect, dignity, and well-being
• rarely, if ever, use humiliation as a tool in child development
• never blame oneself for being humiliated
• seek moderate and peaceful resolutions
• forgive those who do the humiliating
• break destructive cycles
• defuse tension with the sensitive use of humor

At times, humiliation can be a stimulus to personal growth-post-humiliation growth. We may observe such growth in the lives of many well-known leaders: Gandhi, Abraham Lincoln, Richard Nixon, Moses, Jesus, Galileo, even Freud, when he underestimated the Nazi threat and got out just in time.

If humiliation cannot be avoided, let us make the best of it-and help others do the same.

References:

1. Elson M (ed). The Kohut Seminars: On Self Psychology and Psychotherapy With Adolescents and Young Adults. New York: W.W. Norton; 1987.
2. Koestenbaum W. Humiliation. New York: Picador; 2011.
3. Hartling LM, Lindner E, Spalthoff U, Britton M.. Humiliation: a nuclear bomb of emotions? Psicologia Politica. 2013;46:55-76.
4. Sedgwick EK, Frank A (eds). Shame and Its Sisters: A Silvan Tompkins Reader. Durham, NC: Duke University Press; 1995.
5. Lazare A. Shame and humiliation in the medical encounter. Arch Internal Med. 1987;147:1653-1658.
6. Shengold L. Soul Murder Revisited: Thoughts About Therapy, Hate, Love, and Memory. New Haven, CT: Yale University Press. 2000.
7. Otten M, Jonas KF. Humiliation as an intense emotional experience: evidence from the electro-encephalogram. Soc Neurosci. 2014;9:23-25.
8. Lindner E. Making Enemies: Humiliation and International Conflict. Santa Barbara, CA: Praeger; 2006.