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patient’s last words were remorse over acting out on a craving of some sort or another. Common sense would suggest that when people engage in self-destructive actions, particularly those that are socially unacceptable or hurtful to others as well, shame would be common.
    Much has been written on the shame that is involved with addictive or self-destructive behaviors, and unfortunately very little of it has been in the academic/research literature, but one thing is clear: shame appears to be extremely common in people who struggle with cravings. John Bradshaw, in his book Healing the Shame That Binds You, describes the experience, hypothesizing that acting out on eating disorders is essentially a substitution for shame-bound interpersonal needs. In other words, in these people, the desire to be loved, nurtured, and cared for is unacceptable, and inexorably bound up with shame. Food is therefore substituted. However, as Bradshaw writes:
Food can never satisfy the longing and as the longing turns into shame, then one eats more to anesthetize the shame. The meta shame, the shame about eating in secret and binging, is a displacement of affect, a transforming of the shame about self into the shame about food. 37
    Although people sometimes use the terms “guilt” and “shame” interchangeably, from a psychological or treatment perspective we think of them quite differently, and most people seem to sense this difference, even if they don’t express it. In addiction treatment circles, we view shame as the sense that you are particularly flawed in some fundamental way that renders you bad or unworthy of love. With shame, the core thought is “I am a bad person.” On the other hand, guilt is the sense that you’ve done something wrong. The core thought here is “I’ve done something I shouldn’t have.” Guilt is often a healthy emotion, telling us that we need to make things right with someone or that we need to correct our behavior in the future. However, with shame there are no amends or corrective behaviors that can resolve the feeling that you are bad. In this way of looking at shame and guilt, guilt does not threaten a person’s core identity. Shame, however, is devastating to the all-important sense of worth and value that people need in order to navigate their lives with dignity and integrity.
    Culturally, our sense of shame has changed over the last few decades. Some groundbreaking work by Thomas Scheff of the University of California-Santa Barbara has demonstrated that Western societies tend to suppress shame. However, in that same research, Scheff also found that the threshold for shame in Western societies has been decreasing. 38 What that means is that we are both more likely to experience shame and more likely to suppress it, which should be considered a recipe for disaster. As the gap between what we experience and what we can express grows, we get sicker.
    Sometimes people with addiction are so disconnected from their emotions as a result of acting out that they demonstrate what psychologists call neurotic defenses, such as emotional detachment, rather than overt shame. This appears to be more common in men. 39 In those cases, people who are experiencing shame may actually come across as an “emotional wall.” To an observer, they may look as though they aren’t experiencing any emotions at all. They may seem unflappable, as if they are numb or immune to situations that would cause most people to experience (and express) profound emotions. It’s very easy to look at people who are expressing self-pity or self-loathing and see that they are dealing with shame. It’s much more difficult to see the shame behind the tough exterior and detachment of those who seem emotionally numb. In both cases, however, dealing with shame is critical if there is to be any relief.
    Because shame is uncomfortable, many people try to avoid it or pretend it isn’t there, and psychotherapists are not immune to that either.