Adam Blatner, M.D.

December 25, 2008

An intriguing thought occurred to me today. I am beginning to suspect that I was afflicted with a probably adaptive and helpful complex that believed in the power of therapy and may have overlooked the circumstances of people’s lives. Being away from it and on my own growth curve in multiple areas—including continuing insights about my various mild but not insignificant neurotic complexes—and reflecting on how I have been foolish in life, I realized that I have perhaps been a bit too blithe in thinking problems can be significantly helped by therapy.

I am coming to revise this: I have been increasingly impressed with the sheer weight of pathogenic factors in many people’s life. (It’s vaguely akin to trying to promote public health in a community in a third-world country with inadequate sanitation and inadequate water supplies, plus other problems—and the consequent endemic nature of parasitism and fly-borne and other insect and animal born low- and high-grade infections.)

This problem is only hinted at in the official diagnostic manual, under the term “situational” problems or stresses. Such wording implies relatively temporary stress problems. But it seems to me that a number of problems (which will soon be identified) are near-insurmountable. That term refers to the need for levels of stamina and courage that I question whether I could marshal, given such circumstances, and am dubious whether many of my colleagues could, either. Add to these stressors a number of other variables mentioned on some of my web-pages. These are the various factors that could support self-esteem, courage, and stamina, or, in the other direction, could serve to further undermine or deplete such requisite coping capacities. For example, consider that while some people have a superabundance of such qualities as intellect, intellectual humility, a functionally supportive faith and/or supportive social networks, many people have a mild to striking lack of such components of resilience.

Shame and Guilt

Some people mix the two, but I find there to be a useful difference: Shame (as I use the term, and others also see it this way) is more about feelings or behaviors that one cannot help, qualities that seem to be part of oneself. In contrast, guilt is more about impulses or actions that the individual feels s/he could have done differently, could have done more or less, could have held back or been more faithful, loving, responsible. Both dynamics generate slightly different secondary reactions that stir up other reactions in the mind.

This cascading of reactions is important, and very varied. Each complex tends to bring up all sorts of other sensitivities. For example, a person who feels guilty about X may relate that to other difficulties earlier in life.

Some Near-Insurmountable Situations

Let’s now consider some of the real situations:

1. Stuck in an unsatisfactory job; possibly a hated job, or one that is really life-depleting. Sometimes people feel committed to a career that involves increasing demands in many areas, often unrealistic; or is suffused with temptations to drug or alcohol or other addictions as distractions, part of the culture, or for self-medication. (I’m thinking of the plight of Hollywood actors and other celebrities. My fantasy of being a psychiatrist to the Stars gets interrupted by my hearing their story and saying, “You gotta get out of this business. They’re eating your soul alive.” There goes the customer base.

2. Stuck in an unsatisfactory marriage. Divorce is not so easy, especially for folks with kids, or other financial issues. It’s harder if both partners aren’t equally open to the idea. So there’s guilt, constraint, loyalty, and other things. Not all marriages can be repaired, for scores of reasons. Sure, it’s worth trying, but there was a time that I was a bit naive about thinking that most were amenable to counseling.
     A. Then there are those who have left a spouse (perhaps with kids) and have found in subsequent relationships even more dissatisfactions, betrayals, disappointments, and they realize that their complaints about their earlier spouse were blown out of proportion. More guilt.

3. Coping with the financial and sociological circumstances of undesired single-ness, loneliness, being widowed, divorced, wanting to connect and not finding anyone, and (more for women) wanting to connect and not feel pressured into sexuality before one would feel truly safe. The emotional turmoil that comes from this is often underestimated, and many think that an “attitude” can adequately protect one from actual vulnerability.

4. Dealing with kids whom you have begun to dislike, dis-respect; and having kids who may dislike or dis-respect you in turn. These problems can be as painful as other marriage problems, and often involve adult children and grandchildren who live miles away.

5. Coping with significant disability, disease, or threat of death or loss of a partner for such reasons. The many aspects involved require many roles besides the support of a counselor.

6. Coping with financial constraints, of not being able to afford therapy. Now that therapists have often begun to charge way over $50 / hour, and who often imply more-than-brief-therapy is indicated, these are significant stressors in their own right!

7. Shame for an affiliated group’s behavior. This could be whichever group one has identified with as a child or adult. Examples: One’s religion may advocate policies that differ radically with one’s own. A significant sub-set of one’s ethnic, religious, racial, or other minority group may behave in ways that feel alien and outrageous to one’s own morality. Major trends in one’s profession may feel at major variance from what one believed in decades ago. And so forth.

8. Having been a soldier or in other ways involved in a situation in which one behaved brutally, sadistically, towards others. Having been raised to treat folks of other races or religions or other minority status badly, with gross prejudice. Having abused, date-raped, or callously dealt with women. And so forth. Guilt is not so easily relieved when it’s not easy to find peers with whom one can confess and have them agree that it was a bad thing to do rather than to collude in the attitudes that supported the oppressive behavior.

9. Shame and guilt for financial problems, such as taking out a sub-prime loan, getting into insurmountable debt (a fairly pervasive problem in 2008), and so forth.

10. Guilt for participating in the financial dealings that relied on the “everyone is doing it” and “you’ll be a fool if you don’t join in” and “prices are only going to rise further” economic—and moral “bubbles.” Again, tens of thousands of folks in the money management, investment, mortgage broker, banking and other roles—roles once viewed as being conservative—have felt not only betrayed by the system, but also to varying degrees complicit in the meltdown.

11. Guilt for participating in sexual escapades that led to varying degrees of harm to others: not-easily-treated STDs such as Herpes, HIV, etc.; pregnancy and complications—including having the baby and what it does to the mother’s body, economic and psychological stresses, etc.; disruption of those who feel betrayed by the escapades when they find out, etc. (Forgiveness is easier talked about as an abstract category, but actually involves many, many components, not least of which is the sheer difficulty of repairing the harm done.)

12. Guilt for not just becoming addicted or alcoholic, but again for all the harm done to others, the enormous expenses that come from business or marital failures, the emotional, physical abuse, the betrayal of the attempts by loved ones to rescue, and the guilt is appropriately more than doubled for each relapse.

13. All the other kinds of near-addiction that can be equally devastating also leave profound shame and guilt in their wake. I wonder how much the substance-abuse rehab programs really deal with the depth of pain and extent of financial and other disturbances generated in the social networks and sometimes harm to strangers. Addictions include shopping, getting into debt, shoplifting, gambling, bulimia, anorexia, excessive cosmetic surgery or other excessive expenses on trying to be beautiful, glamorous, sexy, or ultra-masculine-buff.
    Other addictions should also be included, such as an expanding appreciation for the addictive potential of video games, passive entertainments of other sorts, and so forth.

14. Guilt and shame also for those who have tolerated being abused for more than a brief period, or for multiple episodes; for those who have colluded with or enabled abusers and those with addictions.

15. Guilt and shame for multiple mental breakdowns, each relapse generating a compounding of the problem. Mixed feelings about attempts to be “strong” and fight the disease, and also what happens when “it” recurs—especially speaking of episodes of depression, mania, schizophrenia, and so forth.

16. Mixed feelings of distrust for supposed helpers who have been disappointing—therapists, doctors, ministers, one’s fellow parishioners at church, extended family, etc.—all of which make it more difficult to generate adequate “treatment alliances.” Often the distrust is based on events that anyone in their right mind would end up feeling distrustful and betrayed—it’s not always a distortion of the “patient.”

17. Living in a region or neighborhood that is scary, deeply uncomfortable, for many reasons (weather, rampant prejudice, etc.), but afraid of moving away for many reasons (e.g., having those perceived to be potentially supportive living nearby, the fear of being a complete stranger in a strange land), and consequent feelings of both being stuck and being guilty/ashamed of one’s cowardice.

18. Having been scammed, taken in, betrayed, by family, friends, or others whom one came to trust. This is a profound violation. It’s worse when this pattern has been repeated. (An old saying: Fool me once, shame on you; fool me twice, shame on me.” But this goes against the ethos of forgiveness and giving folks “another chance” So people feel the conundrum. In fact, there may be a series of manipulations and buying into them—and again, every repeat more than doubles the fixity of the guilt and shame.

19. Having lived in or with a significantly imbalanced relationship (in terms of the perception that one gives far more than another) that goes on for a long time. The lack of reciprocity leads people to feel ashamed for being “doormats.”

20. Forced into split alliances, so that, for example, a middle manager, who is supposed to protect or support his subordinates, is pressured instead to exploit them, fire them, or otherwise betray their loyalty and trust.

Doubtless you may add other examples, and I’d welcome further additions. The point, again, is that many situations are realistically thick in possible consequences. As I said, such challenges might make me feel overwhelmed, so I have become more humble about what I consider to be significantly amenable to mere therapy. Political, social, and other steps may be required.


In our culture, the more publicized problem is robbing a bank, or even murdering someone. Such crimes are bad, no doubt, but often can be attributed to youthful folly or immaturity. Many of the situations are less illegal and high-profile, but often more long-lasting or chronic and life-disturbing and perplexing.

This list is meant to invite people to pause and consider the complex difficulties that come out of a wide range of situations. These are very common. It is questionable whether the cleverest psychotherapist can do much to ameliorate the problems involved.

Of course, given these many problems, there are a number of ways that people make it all worse, through irrational self-talk, over-generalizations, over-reactions, excessive self-blaming, and so forth. Therapy can help reduce these complicating factors. (I’m reminded of the joke of the guy who goes to the doctor with a cold. The doc can’t do anything. “So what should I do?” the patient said. “Maybe go stand in the rain and get pneumonia. That I can treat.”)

This is a provisional group of ideas. What do you think? Help me think this through.