Current interest in shame is examined in its relationship to psychotherapy supervision. Clinician/trainees are vulnerable to exposure and humiliation in the course of their training. This article examines the sources of shame in supervision and offers some suggestions for reducing the shame that might compromise the professional well-being of neophyte clinicians and their supervisors.As the pendulum swings around to more concern about affects in psychoanalytic theories, we have come to see shame and guilt as important byproducts of the uncovering analytic process. Psychoanalytic writers define shame and guilt in a variety of paradigms consistent with their theoretical emphasis. Shame is distinguished from guilt in the psychoanalytic literature by Piers & Singer (1953), who defined guilt as the painful result of a transgression of a superego boundary, and therefore a willful act; shame, on the other hand, is a defect in the self that prevents the person from living up to the ego-ideal. Whereas guilt leads to castration anxiety, shame leads to abandonment and hiding. Furthermore, whereas a person usually feels guilty or not guilty, shame can be experienced along a whole spectrum of discomfort, ranging from awkwardness and embarrassment all the way to corrosive humiliation and fear of disintegration.Freud (1912/1963) and other drive theorists place shame as emerging from the exhibitionistic wishes and fears of the individual. Later in development, anal impulses around the loss of control generate shame. Still later, guilt emerges around the wishes to overwhelm the competitor in the oedipal triangle.

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This paper examines the potential countertransference problems therapists face when they become ill. Personal illness creates conscious and unconscious dilemmas for therapists, and the psychotherapy relationship may be strongly affected by the ways in which the dilemmas are managed. Psychotherapy is a relationship based on trust. A therapist's illness does not necessarily damage the trust that has been developed; however, the handling of the illness and interruption can create a major rupture in the relationship. Alternatively, the therapist's illness can create a useful opportunity for therapeutic work. Successful management of countertransference is a crucial ingredient for the latter outcome. Relatively little has been written until recently on countertransference aspects of therapist illness. Available literature has noted such defenses as denial, omnipotent fantasies, and reaction formation against dependency and weakness. Illness has been seen as a problem for "older" therapists, but, in fact, illness can occur at any age. Illness may cause a defensive withdrawal from one's patients and in its most serious instance lead to total empathic failure. Clinical concerns for the ill therapist fall into two categories: how much (if any) information to give patients about the illness and how to work therapeutically with patients' reactions. While there are no clear guidelines, we recommend a flexible, common sense approach with the central focus always on the patient's reactions to information or to changes in the therapy. The foundation for decisions about information and for subsequent processing of reactions must be the therapist's own awareness of countertransference. We recommend consultation with trusted colleagues or supervisors. In addition, we emphasize the ethical responsibility every therapist has to provide for patients in the event of an emergency ahead of time. Finally, we surveyed a small number of experienced therapists who were known to have had personal experience with illness. The results indicated that decisions about giving information were not difficult. However, the countertransference reactions of anxiety, denial, sadness, and avoidance (of patient anger) were often troublesome. We recommend that psychotherapy training include management of therapist illness. We also recommend that supervisors be familiar with the countertransference aspects as they may be called on suddenly to give consultation. Our conclusion is that therapist illness is as big an event for the therapist as it is for the patient, and we hope that a body of literature will be developed on this important topic.

Written from the perspective of intersubjective theory, this article addresses how the leader and group members co-construct the difficult patient. Too often, therapists and patients have tended to attribute difficulties in therapy groups to "the difficult patient" without appreciating how they themselves contribute to the construction, the needs this construction serves, and the potential value of such patients to the group. Mistakes in group leadership, vicissitudes of intersubjectivity, disturbing intrapsychic defenses, and whole-group dynamics interact to produce the difficult patient. Also discussed is the group member who is difficult but who no longer meets the criteria for patienthood. By exploring the factors involved in the co-construction of the difficult patient, the authors hope to guide clinicians in the deconstruction of such impediments, thus allowing the difficult patient to become "just another group patient."

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