Enactments of contempt and counter-contempt often occur when patient and analyst become embroiled in power struggles about the nature of reality. The patient feels shamed for being deemed “out of touch with reality” while the therapist feels shamed in retaliation for being a moralistic critic making arrogant assertions about the true nature of reality. Working through enactments of contempt and counter-contempt requires that the analyst acknowledge contempt in the countertransference and how it shames the patient. It also requires working toward greater acceptance of patient behavior that seems highly offensive as the analyst may feel shamed by the patient’s contempt for the analyst’s viewpoint, approach to treatment, and personality.