In other words, because most therapist have not experienced their own full shame analysis, they collude with the patient to keep these feelings unrecognized and unexamined. Shame presents in various ways, often very subtle. It is helpful to learn the language of shame. It is also beneficial to become familiar with defenses of shame including addiction, denial, withdrawal, rage, perfectionism, exhibitionism, and arrogance. It is almost always present in patients with impulse control issues.
Shame has different significance in the treatment of different types of pathology.
For the neurotic, it will tend to relate to failure in action, often reflecting defensive passivity against oedipal aggression, competition, and desire. For patients with primarily narcissistic phenomena, shame will be more pervasive and will be in the foreground of all aspects of narcissistic vulnerability. Defenses for these patients will be more active and primitive, often representing manifestations of projective identification. These different manifestations of shame should be explored in an elaboration of the unique shame experience for each patient. Shame itself may very well be hidden, while at the same time it functions as a central concern and experience that must be identified and explored, frequently before authentically useful work can proceed in the interpretation of underlying conflicts and genetic issues.