Humiliation and Its Impact On Our Patients and On Us
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.
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?
Just what is humiliation?
Humiliation: A Nuclear Bomb of Emotions?3
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.