“A woman will feel guilt and shame, but shame will be the emotion she finds most difficult. Guilt is usually associated with a deed that can be forgiven, but shame encompasses her being, taking on an ‘all or nothing’ quality, which has devastating consequences for mental health. Adult daughters of narcissistic mothers often refer to themselves as ‘damaged’ or ‘damaged goods,’ particularly after a series of failed love relationships. Underneath this shame is the feeling that they are unlovable.” (Will I Ever Be Good Enough?: Healing the Daughters of Narcissistic Mothers, by Karyl McBride, Ph.D., p. 110)

In my experience as a person and as a psychotherapist, shame is the emotion that takes the longest to heal. This is because shame is more than an emotion—it is a deep seeded belief that one is not good enough and is irreparably damaged in some way. Group therapy is particularly effective in helping patients to heal this shame. I sometimes say to a patient, “In childhood you were brainwashed into believing that there was something wrong with you.” Implicit in the excruciating feeling of shame is the sense that “others can see that I am flawed or damaged.” Group therapy offers a wonderful opportunity to “test out” this belief, and over time one is able to let go of the “brainwashing,” by experiencing through group members reflections and empathy and care that one is not the flawed person one has so long believed oneself to be.

For the past 25 years I have led a women’s group for “Adult Children of Narcissistic Families.” As a result of growing up in such a family, where children’s needs were subordinate to parental needs, the typical group member, as Dr. McBride suggests in Will I Ever Be Good Enough?, has such trait as “oversensitivity, indecisiveness, self-consciousness, lack of self-trust, inability to succeed in relationships, lack of confidence regardless of our accomplishments, and a general sense of insecurity.” (p. 4)

Starting as a member of a therapy group for a patient with deep shame wounds can be scary and even terrifying. This is because an individual with shame not only believes that she is bad, but even more painfully that others can see this. As I sometimes say to patients, “You take you negative thoughts about yourself and you put them in other people’s heads, believing that they see you as you see yourself.” The new group member imagines that others in the group are judging her, which can make talking about herself particularly difficult. As one woman wrote to me just before beginning the group:

“I’m anxious about starting group therapy, and sitting in here. I wish it wasn’t a problem to sit in a group.” The night after her first group, she wrote to me again: “I was pretty upset after group yesterday. I know I did terrible, but I promise I did the best I could. I’m afraid I won’t be able to contribute. I’m embarrassed. Do you think it will get better? Or do you think I shouldn’t be in the group after all?” Several months later, after a night when I had added two new members to the group, she wrote to me again: “For some reason group is harder with more people…It feels like when I am in group a wall comes up. I can’t put my thoughts together well. I’m busy trying to cover up my emotions. I left feeling inadequate, stupid and alone. I really hate myself right now.” This patient spent many subsequent years in group. She made great progress in overcoming her acute social anxiety and shame, and became one of the most beloved members of the group.

How does psychotherapy heal shame? How is the deep belief in being irreparably damaged replaced with a coherent sense of self and of being okay as one is? David Celani, in his brilliant book The Illusion of Love: Why the Battered Woman Returns to Her Abuser, has described this process: “In truth,” he writes, “it happens slowly over time, like grains of sand falling in an hourglass. Each small positive introject (of the therapist) weighs little individually…Because of the gradual nature of the introjection process, very little appears to happen at the onset of therapy, as there are too few positive introjects to alter the patient’s normal coping strategies.” (pp. 182-183).

Dr. Celani adds, “The struggle between the newly internalized memories and the enormous pressures from inner emptiness turns out to be a David and Goliath battle, as it seems impossible for the fifty-minute hour to compensate for a lifetime of neglect.” (p. 191) While this beautifully describes the work of a good long-term individual psychotherapy, I believe that the positive reflections of an entire group accelerate the process of healing shame and building a coherent sense of self.

During the 25 years of my group’s history, over 100 women have been members of the group. Some have stayed for a few months, and some for as long as 10 years. Many Nashville Psychotherapy Institute (NPI) members have been co-leaders of this group with me over the years, including Kay Hall, Jordan Lee, Lynn Faust Cohen, Julia Marx, April Broussard, and also Christina Oliver when I had a 2nd women’s group.

One group member, after 10 years in the group, called me as she was leaving Nashville to relocate to the Northeast. “I wanted to call you,” she said, “to tell you that this group changed my life.” Over time, group members keep other group members in their mind throughout the week, as a kind of supportive inner chorus. Recently one member talked about how she gets through a challenging week: “I tell myself,” she says, “that I just need to make it until Tuesday night.”

Dr. Elan Golomb, whose book, Trapped in the Mirror: Adult Children of Narcissists in Their Struggle for Self, helped to inspire this group, writes: “Where and how can we see ourselves at all? We need a reliable mirror in which to look, to be accepted as we are, to achieve a sense of being…Group therapy is often useful…Out of our terror, we learn to speak our minds. We start to feel our temper…We find that we have identities of our own…We learn that there is someone inside us…In group, you find out that you are not the only one with a hideous self- image that was put in place by endless parental demands for change.” (pp. 220 & 245)

Like many psychotherapists, as Alice Miller suggests in The Drama of the Gifted Child, I grew up in a narcissistic family. Psychoanalyst Volney Gay describes this as an “inverted self-object” situation, where parents depend on the child to meet their needs. When I was 14 years old and in the 9th grade, I first heard the phrase “inferiority complex.” A light bulb went off in my head, as I said to myself, “That’s how I feel.” My years of playing high school and college basketball, and achieving academically, were driven by efforts to attain what Terrence Real, in his powerful book I Don’t Want To Talk About It: The Secret Legacy of Male Depression, calls “performance-based self-esteem,” which he says will never be a substitute for real self-esteem.

While 40 years of personal psychotherapy has been immensely valuable for me, and has certainly helped me greatly in doing psychotherapy with my patients, I believe that my experiences in group therapy and group process have been most responsible for helping me to feel accepted on a deep level. In 1992 I attended my first meeting of The American Academy of Psychotherapists. Members of the Academy form peer groups which meet several times a year for intense group process. Since 1994, for the past 25 years, I have been one of 14 members of such a “Family Group.” We have met twice each year for 15-20 hours of peer group therapy. In the alchemy of our many years together, and as we have celebrated our successes and mourned our losses, I have experienced my own growth and healing.

I also count my years in groups with many NPI members over the years as part of this healing. I include a peer therapy group that David McMillan and I developed based on the theories of the renowned group therapist Yvonne Agazarian, a peer consultation group for 7 years, 20 years in a peer men’s group, and over 7 years now in an ongoing modern analytic training group, organized by Zach Bryant and led by Austin, Texas, group therapist Jeff Hudson. I often say to patients that one of the goals of psychotherapy is to enable one “to live unselfconsciously in the world.” My group experiences have played a huge role in helping me personally to do this.

Typically, the patients whom I refer to group therapy either have deep shame wounds, or significant social anxiety, or suffer from social isolation. Not counting couples or patients who live out of state, almost 40 per cent of my other 81 adult patients are in group therapy, either in my women’s group, in my men’s group, in the process group I have led for 6 years for psychiatric residents at the Vanderbilt Medical Center, or whom I have referred to the coed interpersonal therapy groups co-led by Christina Oliver and Andrea Barrett and by Zach Bryant and Julia McAninch.

I think back to my first women’s group, 45 years ago, composed of resident hall assistants in the 22-story dormitory where I was the head of residence. This group became the subject of my doctoral dissertation. One night, after a particularly powerful group session, I wrote the following poem:

Soul-guided search
Whisper of light
Fullness.
Precious gift given up
Bathed in stunned silence
“That we might have life,
And have it more abundantly.”
Tonight we began.
We, like a sleeping rumbling giant,
Haltingly forward.
Giant power of love we possess
Beneath our walls and roles.
Did we sense our power tonight?
Why do my tears rise again—mixture of
Agony and joy.
God, can we learn to See each other,
Can we learn to call out from those enclosures
We create for our protection?
Yes, tonight I am alive—as alive as I’ve ever felt.
Have we heard each other a little more clearly?
Can we really believe the strengths we could offer to each other?—
That we could give each other back to ourselves—
Blessed, cradled, loved.