A hidden weight: understanding shame

The elephant in the room

Almost all of us have felt it or seen it in others: a moment when we lower our gaze and cannot look someone in the eye; it is as if a spotlight is shining on just us and we wish we could disappear. The feeling I am describing is shame – a heavy and challenging emotion to understand and navigate. Shame can also be a powerful, often overlooked, barrier to recovery.

"One reason [shame] may be overlooked is that people are often ashamed of their shame, concealing it behind symptoms, withdrawal, or hostility" (Ridenour, Jeremy M., et al. "Shame in the Psychotherapy for Psychosis." Journal of Contemporary Psychotherapy (2026): 1-6).

This blog post on shame is inspired by a recent 2026 paper published in the Journal of Contemporary Psychotherapy co-authored by Brett Thatcher, a clinician at Gould Farm. It brings "metacognitive" insights (basically, how we think about our own thinking) into the everyday conversation about mental health. Shame is an especially important emotion to understand when living with or supporting someone with a serious mental illness. Below is a summary of the article, but first let’s define some terms. 

What is shame (and how is it different from guilt)?

We might feel a sense of guilt and say to ourselves, "I did something bad". This is usually focused on our actions; for example, throwing litter out of a moving vehicle. We know we shouldn’t have done it, but we did it anyway. And we are guilty of the action. "While guilt is an emotion that arises when a person feels remorse about their actions... shame is characterized by a sense of personal inadequacy, especially when there is a significant gap between the actual and ideal self” (Ridenour et al, 2026).   

Shame is the feeling that "I am bad". It is focused on an aspect of our internal self, not our actions. Therefore, it can be much harder to understand, notice, or know how to address. "When ashamed, the individual may feel powerless to change the situation, and the natural tendency is to lower one’s gaze or withdraw to avoid the exposure of these perceived flaws” (Ridenour et al, 2026).   

Internal and external shame

Theorists distinguish between two common ways that shame can show up: internal shame (the “self-critic”) and external shame (the fear of how we are perceived). Internal shame arises when we feel that we have failed to meet our own standards. And external shame arises when a person fears that others see them in a negative light (for example, this is where stigma lives).  

For someone who has experienced psychosis, shame is very important to address because "Shame is an emotion that is known to trigger and exacerbate psychotic symptoms and can lead to negative treatment outcomes" (Ridenour et al, 2026).  

Working with shame 

Because people with psychosis report high levels of shame, it is important for clinicians and family members to understand and work with both external and internal shame. And it is important to keep in mind that “... shame is such a painful feeling that it often leaves people feeling unworthy of love…and therefore it may feel too threatening to share” (Ridenour et al, 2026).  

To help clinicians (and perhaps family members) work with both the internal and external shame of their clients or family members, Ridenour et al (2026) detail particular considerations that address working with shame from a Metacognitive Reflection and Insight Therapy (MERIT) perspective. Below is a brief overview of their considerations (and we recommend reading the entire article for a more in-depth understanding). 

1. Noticing the disguise: Shame often hides behind other things like anger, withdrawal, or "grandiose" behavior. How can we first notice and name these behaviors and then look past the symptom or behavior to inquire into the hurt or pain they are protecting or concealing? 

2. Addressing external shame: It is important to talk openly about stigma and validating the perceived judgment people feel from society as real and painful. "External shame and paranoia are conceptually linked because both are connected to fears of judgment, suspicious thinking, and wariness about receiving unwanted attention from others” (Ridenour et al, 2026). Instead of leaving the person alone with their fears and suspicions, having them share them with a trusted person can help reduce external shame (and paranoia).

3. Reckoning with internal shame: Helping the person (and family) navigate the "mortification" of things said or done during a crisis can help to normalize these things, making them easier to talk about. "It can be painful for patients to read paranoid messages they sent to loved ones or to recall public acts they now find embarrassing... people often felt ashamed of having to acknowledge that their thoughts were delusional” (Ridenour et al, 2026). It is painful to confront the ways someone has disappointed themselves or others, but developing a sense of self-acceptance and curiosity can help.

   
   

4. The power of connection: The relationship (with a therapist or even a family member) can become a safe space where shame can be spoken out loud without the world ending. However, for many adults with mental illness, needing to depend on others might make them feel "weak" or "childish." An individual might feel ashamed of how much they need their parents or therapist. This compounded shame can make them act distant or suspicious because being close to someone feels "risky." This is why it is important to ask questions. "Curiosity may be the antidote to shame" (Ridenour et al, 2026). Instead of judging a behavior, we ask, "I wonder what led to that?" or "What was that experience like for you?" This shifts the focus from "What is wrong with you?" to "Let’s understand this together."

"Curiosity may be the antidote to shame" (Ridenour et al, 2026).

Sitting with the tensions

The article doesn't offer easy fixes for working with shame; but it does acknowledge many tensions that can be generative to live with:

• The tension of "useful" shame: The authors suggest that shame isn't always "toxic”, but it can show us what we value. Can we honor the part of us that feels shame because it means we care about being and doing good, while also releasing a tendency towards self-loathing? "Shame…can also be constructive... Affirming a patient’s moral capacity for self-assessment can help combat stigma” (Ridenour et al, 2026).

• The tension of disclosure: If someone is ashamed of their delusions or past behaviors, how do we balance the need to be honest about the past with the need to protect our dignity in the present? "Grieving these losses may ultimately enable the patient to accept perceived flaws, although the process will be painful as the person confronts the ways they have disappointed themselves and others” (Ridenour et al, 2026). 

• The tension of dependency: The article mentions that feeling "close" to someone can trigger shame (feeling "weak" for needing help). How do we accept love and support without feeling diminished by it? "Helping people to form more complex and flexible ideas about themselves and others offers a framework that may allow people to find meaning within experiences linked with shame and thereby weaken the power of shame" (Ridenour et al, 2026) and increase their ability to connect deeply again with others around them.

Bring it to light: shame thrives in secrecy

Shame thrives in secrecy and has the power to hold someone apart from feeling belonging and connection. For individuals with serious mental illness, social isolation is often a significant source of distress already. When you layer experiences of shame on top of that experience of isolation, the individual can feel incredibly lost, alone, and disconnected. This can complicate recovery and exacerbate many other symptoms, including paranoia. By bringing shame to light through conversation and relationship, Ridenour et al propose that the experience of shame can be moderated. Within a therapeutic relationship, a framework can be developed with the person experiencing shame where they can conceive of themselves and the world with a more flexible mindset. This kind of meaning-making can then “weaken the power of shame” and help bring the individual back into relationship with self and others.