Stained? Mental Health Services, Spaces and Shame
Dear Outpatient Clinic,
I won’t be coming to my next appointment; please transfer my medical records to the address below. Judith Lewis Herman, who first characterized complex PTSD, calls it a “shame disorder” . The inability to act when the self is at stake causes a person to doubt, even to loathe, herself. Trauma is shame; complex trauma is shame that lasts long enough that there is very little ‘self’ left by the end. Trauma is one type of loss of self. Depression, anxiety, and many others – often in tandem – also chip away at the self-worth of your clients.
We all come to your clinic with different stories, but mostly we all share stories in which we have cast ourselves, or been cast, as villains. My trauma history included the use of mental illness as a form of emotional abuse. Instead of inherently believing your clinic was a safe space, I was fighting years of conditioning telling me that sharing my story would leave me betrayed. I was fighting the knowledge that, though I came voluntarily, you ultimately held the power of the pen. What you wrote on your clipboard determined whether I’d be shown sympathy or scorn.
Mental health stigma by practitioners is not as dire as I was originally coerced to believe, but it is real. I came knowing that research shows that the same patient often receives very different care if she presents with PTSD vs. BPD, is called “non-compliant” vs. “treatment-resistant” in her depression, and that rarely is the patient asked for consent before a label is written on the page . I believed others wrote my story. I chose to walk through your doors anyway and to trust as best I could.
A clinic or a prison?
I chose again to overlook metal doors, locked in like a prison. When the doors buzzed, I walked through. “They administer controlled substances for substance abuse treatment,” I rationalized. “It’s only logical they have more security. They are protecting their clients from the world, not themselves from their clients?” Besides, I reasoned, “My new insurance assigned me here, and my meds are working. I shouldn’t mess with them now, not with a new job, in a new city. Get the refill; decide later.”
I didn’t expect to have to overlook spilled coffee, in a viscous oozing puddle, that no one cared enough to clean. People with trauma histories often feel – are made to feel – stained. We are coached in therapy to show ourselves kindness, to love ourselves, to believe we were not sullied at our core by trauma and/or mental illness. Why should I believe you, when you showed me that first day how much you valued my dignity? I wasn’t even worthy of a washcloth.
I don’t know why
Why did I keep my follow-up appointment? I don’t know except that it was already made, and my insurance, quite frankly, wasn’t getting back to me. I accepted I didn’t need more and I told myself it didn’t mean I didn’t deserve more. The stain was still there at my next appointment. Just an amorphous blob on an old floor, as tired and forlorn as the ripped 1970s orange vinyl chair above it.
I am grateful your clinic was not the first I visited. My previous therapist showed her clients – sliding-scale fee or Cadillac-plan insurance – their value in soft lighting, comfy couches and vacuumed floors. In live plants, not fake or dead, and in private waiting areas instead of public pens. If shame is in the stain, then dignity is in those details. Her exterior matched the interior she claimed she saw within me. Your exterior matched the interior I believed was within me.
I am not shameful
You told me – but didn’t show me – that I was not shameful. I guess I choose to believe it after all. Now I insist that my next clinic bolster, not batter, my fragile self-esteem. I thank that previous clinician whom I saw create safety, security, and self-worth in her spaces. I beg you to learn from these contrasts the central narrative of shame in social services, and in the spaces in which they are offered. The severity of shame is a key predictor of the severity of PTSD, but it is also a key predictor of therapy success .
Judith Lewis Herman also noted that, “Chronically traumatized patients have an exquisite attunement to unconscious and nonverbal communication” . You, my clinician, didn’t ask what I read that made me decide to transfer, but I’m telling you anyway. I read clearly what little value you assigned me when I saw that stain and I want you to know that I deserve better. I am better, and so is every other one of the ‘selves’ you treat, from the homeless man with addictions to the person with schizophrenia experiencing psychosis, to the self-harming teenager, to the upper-middle-class professional.
An Unstained Survivor
 Herman, J. L. (2011). Posttraumatic stress disorder as a shame disorder.
 Herman, J. L. (1997). Trauma and recovery (Vol. 551). Basic books.
 Saraiya, T., & Lopez-Castro, T. (2016). Ashamed and Afraid: A Scoping Review of the Role of Shame in Post-Traumatic Stress Disorder (PTSD). Journal of clinical medicine, 5(11), 94.