hypersexual disorder

The Case Of George…

Unveiling the Hidden Self (part 2)

shame shutterstock_16378152

Today we look at a clinical study (vignette) of a patient who suffered emotional neglect as a child to show how developmental trauma can dramatically affect the patient’s personality and behaviour. in this case, it led to negative expectations towards interpersonal relationships, disturbing feelings of shame, and a sense of a defective self.

These shame experiences deriving from the internalisation of bad or unworthy parents are subsequently linked to some psychopathological manifestations, such as withdrawal from social contacts, narcissistic rage, addiction and perversions.

Here, we look specifically look at how a profound sense of shame and inadequacy can lead to compulsive  internet use around sexual fantasy and acting out these fantasies.


Case study:- George

Fossum and Mason (1986) compare feelings of shame to a dragon, a terrific monster capable of metamorphosis and invisibility. Coping with the monster is a feat, as represented in the iconography of the battle between St. George and the Dragon…the courage required by the hero to save the virgin from the dragon can be compared to the courage needed to free one’s own soul from something disgusting and intolerable (akin to the stench emanating from the dragon’s mouth).

In more clinical terms, an individual must have developed a sense of security in order to tolerate the painful experience of facing his own monsters and that sense of security must be stronger than the fear of succumbing to the monsters. When I met George for the first time, he was a shy young man in his early twenties. He was a kind blue-eyed man, who was tall and fit. But he felt ugly and was convinced that people saw him as a stupid and childish person because he was not as socially competent as his friends.

George grew up in a disturbed family. His mother was intrusive and emotionally unreachable at the same time; she was usually very angry with George, belittling and humiliating him in every way. His father was apparently caring, but would share with George the details of his marital problems. Accordingly, there was a significant role reversal, and George was used as a container for his father’s anxiety. Such a relationship with parents had disruptive effects on George’s approach to life, both at an intrapsychic and interpersonal level.

George was confused about his body image and sexual identity. He suffered from obsessive ruminations about the possibility that he was a homosexual, but also had the desire to date women. With this conflict, he was overcome by shame and a fear of humiliation. George predicted that he would never experience an intimate relationship with a woman, as he saw women as exciting but also potentially exploitative and damaging.

In fact, he often dreamt about a terrifying witch who would suddenly appear out of nowhere and terrorise him. This uncanny witch represented in my view the internalised image of his mother, whom George experienced as an omnipotent and unforgiving judge of his feelings and behaviours. George’s unconscious idea that women were dangerous like his mother deeply impacted on his sense of self-worth and also exacerbated feelings of shame and fear that he might be homosexual.

George indeed had negative expectations about the possibility of being accepted and cared for. He believed he did not deserve a better life because there was something essentially wrong with him. Furthermore, his ability to self-regulate and his affect tolerance were low. He was resentful towards his mother and sometimes towards his father too, yet because he was deeply insecure he continued to ask his parents for a magical solution to his problems.

In summary, George’s developmental trauma had generated the internalisation of bad and untrustworthy objects, and consequently he relied on splitting and dissociative mechanisms to protect himself from a mental breakdown. But the price he was paying was really high: he was at risk of surrendering to the internalised bad objects and believing himself to be so unworthy and stupid that he did not deserve affection from anyone.

The weekly psychological consultations with George lasted for four years. Honestly, most of the time I spent with George I was trying to understand and help repair the psychic damage which had resulted from failures in parental care. I was also searching for a way to increase George’s trust towards the relational world. This turned out to be very difficult because George was particularly susceptible to feelings of unworthiness, and each negative relationship he experienced only strengthened his pathological belief that the world would reject and humiliate him. Furthermore, because of George’s low capacity for modulating affect, when he became aware of his own anger, he would lash out verbally. Subsequently, he would feel guilty, which only increased his belief that he was a bad person.

However, while guilt was often George’s conscious state of mind, disruptive feelings of shame were behind it…shame is often considered a more painful emotion because it involves a negative evaluation of the entire self, whereas feelings of guilt tend to be directed at specific behaviours which are inconsistent with one’s own moral standards. Feelings of shame are typically characterised by a sense of worthlessness and powerlessness, thus not simply one’s own behaviour, but even the core self is at stake. Furthermore, shame engenders a desire to escape, hide or to lash out at the person in whose eyes one feels ashamed, whereas guilt engenders a desire to make some amends or an act of reparation (Lewis, 1987a).

The following is a report of a crucial moment in the clinical work with George, that helped me understand the role shame played in his psychic functioning. This episode happened three years after the beginning of our work. At the time, George was finally involved in a romantic relationship with a young woman. This relationship seemed to be marked by emotional stability, mutual attraction and shared affection. George sometimes expressed concerns about the relationship, but I was prone to see these concerns as a normal reaction for someone who had grown up with unpredictable caregivers.

I was blind to the truth. At the beginning of this romantic relationship, George started conversing online with women he did not know. He would contact women through Internet chat-rooms or social network sites, and engage in sexually explicit conversations while masturbating. He kept this a secret from his partner and for some time from me. When George finally decided to tell me about his online interactions, he appeared to be overwhelmed with guilt. When George confessed to this behaviour, I experienced a strong sense of personal discomfort. Up until then, I had been enthusiastially remarking that his life seemed to be improving, but now I felt that, in my overeagerness to look for his psychological recovery, I had been less than effective as a clinician, in that I had failed to understand the depth of his symptoms.

At that point, I tried to examine more closely my own emotional response to George’s confession, and I found myself experiencing a strong sense of powerlessness that made me feel unworthy and clumsy. Then, I began considering my own feelings of shame as the possible result of a transference-countertransference dynamic…

George’s parents left him alone with his doubts, devalued his fears and pushed him to mask his true feelings, so that they would not be emotionally disturbed by him; I was probably doing the same, in that I was pressing George to present himself as much more secure and clinically improved than he really was, because I was scared of looking through the depth of his psychic pain. I, too, was unconsciously defending myself against feelings of shame, in order to avoid feeling incompetent as a clinician because I was not able to help George…

Fortunately, George’s confession allowed me to move towards another level of resonance with his self-experience. I realised that, in the hope of finding containment, George was unconsciously projecting shame into me, with a need for me to give back the shameful feelings to him in a more tolerable form…So, now I could feel inside myself the sense of inadequacy and unworthiness deriving from George’s developmental trauma. In this way, I became aware of George’s debilitating feelings of shame, and I understood that shame was probably playing a determinant role in the development of his behaviours on the internet, but also that his entire psychic functioning was organised around shame.


So, I tried to explore with George what was going on for him before he initiated online sex, and he reported that usually he had been upset by something, such as an argument with his girlfriend or a negative interaction with his mother. In that moment of anger, George was not able to cope with his upsetting feelings by expressing his emotions, because he feared the eventual consequences of being abandoned or neglected. So, I thought that George was engaging in online sex and compulsive masturbation in order to regulate his strong sense of ineffectiveness and inadequacy.

More specifically, I believed that he was coping with feelings of shame he experienced in his relationships with his mother and girlfriend by using the defense mechanism of reversal into the opposite (Freud, 1915); he was playing out his fantasies of domination by controlling the interaction with women over the Internet, thus becoming the one with the power in the relationship. I also believed that George was using the primitive defense of sexualisation; in fact, from a developmental perspective, sexualisation as a defense mechanism tends to correspond with the transformation of anxiety and depression into excitation and pleasure (Fraiberg, 1982). So, it might be that George was eroticising stressful events through online sexual interactions in an effort to protect himself from the awareness of having unloving parents.

I shared all these thoughts – including my own sense of defectiveness – with George, trying to use as much tact as I could (Ferenczi, 1912) to avoid eliciting further feelings of shame. I started to feel a deeper intimacy between us while doing this; I felt that something new was emerging in our relationship, about the possibility of mutually sharing affects and meanings.

George looked at me with shining eyes, as if he could actually deal with feelings of shame without getting scared, because there was a relationship that affectively recognised and validated those feelings. I think this episode was important for the development of George’s ability to identify and express his feelings in an honest way, even when struggling with emotional distress or conflict.

Later, it was crucial for George to work through such complex feelings of shame, fear of abandonment and revenge, as this helped him to accept that his emotions were real, meaningful and might be positively used to enhance his behaviours and improve his interpersonal relationships. In addition, this episode seemed to help George understand the origins of his impulsive and compulsive use of erotic chat-rooms, and he quickly discontinued this behaviour.

However, I am convinced that it was the discussion of shame that was most healing for George, because it took place in a relationship we eventually could perceive as trustworthy and sincere: in that situation, George saw that I was listening to his true feelings without judgement, and that I was similarly experiencing feelings of shame but I was using them for the growth of our relationship. In the end, working on feelings of shame helped George to understand that early damage could be repaired in the relational world.


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