Shame is one of the most painful human emotions. While it can serve adaptive social functions, chronic shame is linked to depression, anxiety, trauma-related symptoms, eating disorders, substance misuse, and self-directed harm. When shame becomes fused with a person’s identity, it often drives patterns of withdrawal, perfectionism, and harsh self-criticism.
A recent case study by Kati Lear, PhD and Jason Luoma, PhD from Portland Psychotherapy examines how Acceptance and Commitment Therapy (ACT) can help people transform chronic shame by increasing psychological flexibility and self-compassion. The paper follows the treatment of one client and offers a detailed look at how this approach works in practice.
Understanding Shame Through an ACT Lens
The authors begin by reframing shame. Rather than treating shame as inherently pathological, they describe it as an evolutionarily shaped emotion designed to protect social belonging. Shame can motivate repair and cooperation when people believe connection is still possible. But when shame becomes generalized and fused with identity, it can lead to rigid avoidance and relentless self-criticism.
From an ACT perspective, the problem is not the presence of shame itself. The difficulty arises when people respond inflexibly to shame. This often shows up in two ways:
- Avoiding situations that might trigger shame
- Becoming fused with self-critical thoughts and treating them as facts
Over time, these strategies shrink a person’s life. They may temporarily reduce distress, but they reinforce the belief that something is fundamentally wrong with them.
The Role of Social Safeness
A central concept in this case study is “social safeness.” Drawing from affective science, the authors describe four emotion regulation systems: threat, drive, shutdown, and social safeness.
Shame is closely tied to the threat system. When activated, the body prepares to defend, withdraw, or submit. Chronic activation of this system, especially alongside self-criticism, can leave people exhausted and brittle.
Social safeness, in contrast, is associated with warmth, connection, and belonging. It is activated by cues of care and compassion, both from others and toward oneself. According to the authors, cultivating social safeness creates the physiological and psychological conditions necessary for flexibility.
In other words, people respond more effectively to shame when they feel safe.
The Case of “Courtney”
The case study follows “Courtney,” a woman in her late thirties experiencing depression, anxiety, and persistent feelings of inadequacy. Though successful in her career and devoted to her family, she felt like an imposter and was highly self-critical. She often withdrew when ashamed and spent hours overpreparing to avoid mistakes.
Treatment lasted 20 sessions and began with a preparation phase. This included exploring the origins of her shame and self-criticism, identifying early experiences that shaped her self-concept, and building a less self-blaming understanding of her patterns.
A key early intervention involved identifying sources of warmth and care in her life. By reconnecting with memories of being loved and supported, Courtney accessed a felt sense of social safeness that later became a therapeutic resource.
Building Self-Compassion and Flexibility
Several core ACT processes were used throughout treatment:
1. Defusion from Self-Criticism
Courtney practiced noticing self-critical thoughts as mental events rather than truths. Exercises such as labeling thoughts (“I’m having the thought that I’m inadequate”) and two-chair dialogues helped her create psychological distance from her inner critic.
2. Lovingkindness Meditation
Lovingkindness practice was introduced to cultivate social safeness internally. Courtney began by directing compassion toward someone she loved, then gradually extended that same warmth toward herself. Over time, this reduced the intensity of her self-criticism.
3. Exposure to Shame
Rather than avoiding shame triggers, Courtney practiced intentionally contacting shame in session. Through guided imagery and perspective-taking exercises, she learned to respond with compassion instead of criticism. For example, she imagined viewing herself through her daughter’s eyes, which evoked tenderness instead of contempt.
4. Values-Based Action
Courtney practiced making choices aligned with her values, even when shame was present. This included spending evenings with her family instead of overworking and reaching out for support when feeling lonely.
Outcomes
By the end of therapy, Courtney reported significant reductions in shame and self-criticism, along with increased self-compassion. She felt more connected to her husband and daughter and was more present in daily life. Importantly, she did not eliminate shame altogether. Instead, she developed the ability to notice shame without automatically withdrawing or attacking herself.
This shift reflects increased psychological flexibility. Rather than being driven by threat and avoidance, she could choose responses aligned with her values of love, warmth, and connection.
Why This Matters
This case illustrates that shame does not have to be eradicated to improve well-being. What matters is how people relate to it. By strengthening social safeness and cultivating self-compassion, ACT helps people respond to shame with openness and flexibility rather than rigidity and self-attack.
For clinicians, this study highlights the importance of addressing shame directly and systematically building compassionate responding. For people struggling with chronic self-criticism, it offers a hopeful message: shame may be powerful, but it does not have to define who you are or how you live.
You can read the full pre-print of the case study here.
For ACT clinicians and trainees: If you work with shame, self-criticism, or trauma-related conditions, see Portland Psychotherapy’s ACT training and consultation offerings for clinicians.
