The pain just makes me feel desperate for some relief, but it’s hopeless. I have no energy to do anything. I’m just worthless; no wonder people ignore me. I am so lonely. Nobody seems to care. If I start to think things will improve, the pain comes back and I can’t do anything. It’s like I have the word loser tattooed on my forehead.’
Feelings of inadequacy and shame are so often the silent witnesses to any psychological consultation for IBS. After all, there is little more embarrassing than the smells, gurgles, and pain of unruly bowels. The toilet is the locked room of shame, where you struggle to carry out a bodily function that nobody witnesses. Even members of the same family or close friends may know nothing about what happens there. But not only are the travails of this most private of bodily functions a source of embarrassment, but by association, disturbances in bowel function is often the route by which shame and its associated feelings of guilt, regret, inadequacy and diffidence are expressed.
Is it a group of bodily sensations or reactions? Is it a emotion expressed in the gut? Is it a collection of negative thoughts? Is it memory, the bodily residue of something that happened so long ago we cannot recall it? Or is it a feeling that encompasses all of those? Doctors and dietitians tend to instrumentalise IBS, turning it into something only they can deal with, but can it sometimes be something far deeper and more personal?
Is it the same kind of phenomenon as the terms patients use to describe it. Shame, desperation, loneliness are not just emotions; they are also bodily sensations and modalities of thought. They incorporate components of grief, guilt, frustration, grievance, pain and anxiety. Recent discoveries in neuroscience indicate that consciousness and ‘feelings’ are generated in the primitive midline regions of the brain stem that not only express emotions but also regulate visceral functions via the hypothalamus and autonomic nervous system. Impulses from these same ‘centres’ feed into the cognitive and associative centres of the forebrain, affecting how we think .
Shame, however, seems to represent a sink or drain for all kinds of negative personal feelings associated with trauma; the longer they last the more they tend to gravitate to shame. Even positive feelings of joy, confidence, desire and exuberance can be replaced by shame if we are not able to keep them under control. Shame can control a person’s life, stopping them from doing things they might otherwise enjoy, preventing them from risking any change, infecting whatever they may want to do. ‘I can’t possibly do that. What’s the point? It will never work out.” Patients express the same epithets in regard to IBS and other unexplained bodily ailments.
But, you may point out, we can all feel inadequate, embarrassed or ashamed from time to time. It’s what keeps us safe; shame is a course correction that curbs our impulses, encourages learning and enables us to function with confidence and responsibility in society. The neurobiologist, Allan Shore, declared that shame develops during toddlerhood as a ‘neurobiological regulator’. Children are naturally curious; they want to explore their environment, but they have no concept of what is safe and so need guidance from their parents. ‘No’ is said to be the most important word an infant ever hears. A sharp telling off rectifies their behaviour and they remember the lesson – not as a ‘rule’, but more as a caution. As long as their parents can guide with firmness, forgiveness and kindness, they ‘learn’ the association between the context and the feeling, avoid the situation, curb their behaviour and continue to develop in safety and confidence. But if misdemeanours are never forgiven or are reinforced by threat (‘If you do that again, your dad will give you such a hiding’), feelings of shame can persist and infect their body, their mind and the meaning they attribute to situations. This is how neglect and abuse in infancy can lead to life long emotional and bodily illness; such children can all too readily come feel they are bad. Sometimes, shame can be institutionalised. The Roman Catholic concept of original sin instructs believers to atone for the sins of mankind which will remain with them for the rest of their lives.
Shame and its concomitant emotional and bodily feelings are also inevitable camp followers to unresolved trauma later in life. The early effects of trauma: the nightmares, flashbacks, anger and fear, are suppressed but are replaced by long lasting feelings of depression, shame, and the bodily memories that represent those feelings. These symptoms may be regarded as a refuge that protects sufferers from risk, but unresolved, may also become their identity; the prison that the self cannot escape from. People, who have been abused, imprisoned or witnessed atrocities in armed conflict, may suffer the shame of what happened for the rest of their lives. But it’s not just major trauma. Often the experiences that leave such a residue of shame are the sort of life events and personal reversals that most of us experience; bullying or teasing at school, the divorce of ones parents, disappointment in our career, guilt at hurting someone we loved, the break up of a relationship, estrangement from our children. Our reactions to those events, however, frequently have their origins in feelings of threat or abandonment that we experienced as a child before we could understand or could report what was happening.
While fear and anger are directed towards the source of threat, shame is internalised and much more personal. It may be associated with activation of the sympathetic (it’s not safe, I can’t trust anyone, it feels desperate) or parasympathetic nervous systems (it’s hopeless and I’m worthless). Shame distances a person from the trauma, appeases others and limits damage by blocking impulsivity and allowing more time to think and learn from what has happened. In those regards, shame may help people survive what happened. The shameful memories steer them away from harmful situations and behaviour, changing the course of their lives and shaping who they are. The same applies to other implicit memories induced by trauma: the anxiety, grievance and the whole gamut of debilitating bodily symptoms. ‘Oh, what’s the point in trying? It will never work out.’
Most of the people I see with IBS are desperate to get out of their pit of despondency and enjoy life. Some may try to rise above it by exuberant attempts to embrace life; partying, extreme sports, dating, working, drinking or taking drugs; although these may provide brief satisfaction, all too often, they lead to a rebound in symptoms. Some may be lucky and find somebody who loves them and can restore feelings of self worth. Love, it is said, conquers all; and for a time it does. Call me an old cynic, but insecure couples while craving the affirmation that love offers, may encounter the same old feelings of shame when, fearing abandonment, rejection and loneliness, they may try to restrict and undermine each other by mutual recrimination.
A few years ago, at The IBS Network’s anniversary conference, erstwhile patients reported how they had escaped from the trap of their IBS by discovering a purpose in life that fulfilled them and with that, a future of hope and possibility. Unfortunately, too many others can teeter on the brink of life, waiting for a sign. One of my recent patients seemed poised to fly but could not let go, so in a departure from psychoanalytic abstinence, I said, ‘just do it’, and he did, like a fledgeling guillemot launching itself off the cliff ledge. Unfortunately, psychoanalysis can encourage so much internal rumination that clients can remain in a futile cycle of shame and more therapy as they become ever more intrigued by the mystery of their own misery.
There are other ways. The psychotherapist, Janina Fisher, surprises clients with the possibility of change by asking them how their illness helps them survive. By questioning their fear, she encourages patients to rediscover hope and take the risk of freedom, self sufficiency and acceptance. Techniques, borrowed from ‘Sensorimotor Psychotherapy’ help her patients notice patterns of feeling, thought and behaviour and question how they express what happened, what triggers them and whether they are still relevant. She uses bodily resources, such as placing a hand on the heart, straightening the spine, or breathing to disrupt automatic thoughts and responses and create new opportunities, transforming engrained implicit (unconscious) memory traces. Naming the shame as the child part of their personality may help patients understand and feel compassion for the traumatised self and want to heal it rather than reject it. By encouraging patients to notice what happens as a body sensation, an emotion and a thought, sensorimotor therapists can help them gain distance from the illness and transform the habitual organisation of experience.
In IBS, that has been instigated by trauma, shame and other mental and physical symptoms are so often memories that are no longer relevant and can be relinquished. And thoughts are just theories; the stories we make up to make sense of what is happening. They need not define us. Sensorimotor therapists engage their clients in a conversational ‘dance’, encouraging them to ‘drop the content’ and create positive memories that encourage curiosity and hope.
On the radio, the other day, I heard how techniques of virtual reality might be employed to change the way people may learn to reformulate what happened and repair the effects of regret and shame. So will therapists be replaced by avatars? And is the future always risky?