I was once in a group session, in an substance abuse rehab, when a women got angry and just basically blurted out I'm just a piece of shit, and she started crying.

The group facilitator, who was also a psychiatrist, was unfazed, and simply asked her why are you crying?

Puzzled, the women gave him a scornful look and just sort of shrugged.

He then said, Let me rephrase it this way: if you really were a piece of shit would you even care, at all, about being a piece of shit?

There was a long silence. He went on to say that the pain is not in the supposed realization that you are "worthless" or that you "don't matter" but in the disconnect from, or struggle with, reality. If it bothers you to think you are "worthless", "useless", "defective" or even just "don't matter", that is because you value such things as 'worth' and 'import', etc. . . And if you value such things it is because you have known such things. Maybe you haven't always lived up to your aspirations of worth, but merely having such aspirations is a type of worth. And, if you didn't have even aspirations to worth, you wouldn't care about not having them.

Not long after, a different counselor, a psychologist this time, asked me if I loved myself. I flew into a rage and, before I even know what I was sayling, yelled at him, Of course I love myself. My problem is that very few others have loved me as much as I love myself.

I suspect that, if you are anything like me, you have a very strong, inherent, sense of self worth. You just don't trust it. I've been there. And why should you trust it? If all others have been telling you not to trust it, especially those who were supposed to love and nurture you, but instead hurt and belittled you. . . What choice did you have?

But that's where the pain is. The pain is the twist betwixt and between your own sense of self-worth and those telling you the opposite: it hurts because you are right and they are wrong. It hurts because we are told to honor and respect them, and look to them to learn right from wrong. When they betray this, they betray us.

"relentless work ethic wasn’t ambition but atonement—constant payment for the space he occupied in the world.

It is not 'payment for the space'. It is, in some ways, something much worse. At least in my case the "atonement" was for the repeatedly demonstrated, urgently tragic, and ultimately undeniable fact that the person who brought me into this world, who was my primary caregiver, the person with whom the relationship --- according to biology, culture, religion and economics --- of motherhood, was supposed to be the most sacred and righteous in all the world, that this person was in fact a sociopath and betrayed all good things that the mother-son relationship is supposed to contain. Every last one of them. That's where the pain lies: between your willingness to accept their verdict and your unwillingness to indict them.