Shame Dynamics in the Psychotherapy of the Patient with PTSD: A Viewpoint

In explicating a treatment approach to the PTSD patient, I must first distinguish the altered ego state, which I will call the posttraumatic state and which results from trauma, from the traumatic event itself. This posttraumatic state gives rise to shame and to defenses that keep shame-arousing awareness from consciousness. Put simply, endopsychic awareness of the increased neediness of human contact and of the propensity to disorganize if these needs are not met, puts the trauma sufferer at variance with his or her own standards and ideals for adult poise, integrity, and autonomy. This risk of exposure as failing to meet those standards gives rise to shame and defenses that ward off shame-producing awareness. These shame dynamics involving the posttraumatic state were revealed dramatically in the course of a 7-year study of posttraumatic nightmares (Lansky and Bley, 1995). These nightmares proved to be true dreams, not merely affect-laden memories, and provided a royal road to the understanding of the fragile, fragmentation-prone posttraumatic state and the shame dynamics that accompany it. Understanding of these shame dynamics provides the basis for a psychotherapeutic approach to the PTSD patient.

Freud (1900, 1920, 1933) assumed that the dream scenario of traumatic dreams portrayed the essence of what is traumatic about the trauma and that there was no latent content of importance in such dreams, which were more memories than true dreams. There was no need to consider defense, disguise, wish fulfillment, and conflict other than that in the manifest dream. Accordingly, the manifest conflict in the nightmare—usually a situation of external danger accompanied by terror and occasionally by remorse—was the central issue in treatment. The nightmare, then, was to be considered part of a response to danger or stress and treated as something apart from a true dream. Detailed investigation of dozens of posttraumatic nightmares, acute and