Portland Psychotherapy Team

Addressing Internalized Shame in Justice-Involved Women with Substance Use Disorders: Insights from a New Study 

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Internalized shame presents a significant challenge for people seeking recovery, particularly among justice-involved women with substance use disorders (SUD). Shame, compounded by societal stigma, often impedes the recovery process. For this population, mindfulness-based relapse prevention (MBRP) emerges as a promising approach to addressing internalized shame and fostering justice-involved women’s recovery. A recent study, co-authored by Dr. Jason Luoma, explores how internalized shame evolves during SUD treatment and highlights MBRP’s potential as a therapeutic intervention. 

Why Focus on Shame and Justice-Involved Women? 

Shame, a deeply personal emotion, can develop when people internalize stigmatizing beliefs about themselves. For justice-involved women, societal stigma can be especially pervasive, intersecting with gendered expectations around roles such as motherhood. Research highlights that internalized shame can impair treatment outcomes, reduce self-esteem, and lead to avoidance behaviors that hinder recovery. Studies have also shown a correlation between shame and relapse rates, making it crucial to address shame for long-term recovery success. 

Study Overview 

This secondary analysis focused on 105 women undergoing residential SUD treatment in a nonprofit facility in the Pacific Northwest. Participants, many of whom had faced incarceration or nonviolent substance-related charges, were randomized into two groups: one received MBRP, while the other received traditional relapse prevention (RP). Both interventions aimed to equip participants with strategies for managing cravings and high-risk situations. Mindfulness, a key component of MBRP, emphasized acceptance and non-judgment of present-moment experiences—a potential cornerstone for reducing internalized shame in substance use disorder (SUD) recovery. 

Key Findings 

The study identified significant reductions in internalized shame across both treatment groups from baseline to post-treatment. While participants in the MBRP group showed slightly greater reductions, the difference was not statistically significant. These findings suggest that both interventions, when delivered in a supportive group setting, can foster an environment that alleviates feelings of shame and isolation. 

Importantly, the study also confirmed the reliability of the Internalized Shame Scale (ISS) in this context, establishing that it accurately measures internalized shame across different treatment conditions and time points. This marks a critical step for future research into shame as a measurable construct within SUD treatment. 

Mindfulness and Its Role in Shame Reduction 

Mindfulness-based interventions have shown promise in addressing shame by encouraging people to observe their thoughts and feelings without criticism. Previous studies have linked increased mindfulness with improved self-esteem and reduced emotional distress. In this study, MBRP’s mindfulness practices appeared to help participants develop greater acceptance and reduce avoidance behaviors, potentially lessening the grip of shame over their self-perception. 

For justice-involved women, who often face unique societal and systemic pressures, these benefits are especially noteworthy. The structured group setting, shared experiences, and mindfulness techniques may collectively work to break the cycle of self-stigmatization and promote recovery. 

Implications for Practice 

This study provides valuable insights into the potential for addressing shame within SUD treatment settings. Here are some practical takeaways: 

Incorporating Mindfulness Practices: Whether through MBRP or integrated into traditional approaches, mindfulness can empower people to confront and accept their experiences, fostering resilience in recovery. 

Tailored Interventions for Justice-Involved Women: Treatment programs should consider the unique stigma-related challenges faced by this group, such as the societal judgment of mothers with SUD histories. 

Building Supportive Group Environments: The group dynamic in both MBRP and RP was identified as a key factor in reducing feelings of isolation, an emotion often intertwined with shame. 

Looking Ahead 

While this study offers promising insights, it also underscores the need for further research. Future studies could explore how specific components of MBRP, or other mindfulness-based interventions contribute to reducing shame. Additionally, expanding sample sizes and exploring long-term outcomes beyond 15 weeks post-treatment could provide a more comprehensive understanding of these interventions’ effectiveness. 

Conclusion 

This study highlights the complex interplay of shame, stigma, and recovery in justice-involved women with SUD. Mindfulness-based relapse prevention (MBRP) offers a promising approach to reducing internalized shame in substance use disorder (SUD) treatment. By integrating mindfulness techniques and fostering group support, MBRP can empower justice-involved women’s recovery, offering hope for those navigating the challenges of stigma and shame. As research continues to illuminate effective strategies, treatment programs can better address these barriers, paving the way for more compassionate and inclusive recovery pathways. 

Download a pre-print copy here 

Exploring the Role of Psychological Inflexibility, Mindfulness, and Self-Compassion in PTSD  

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Post-Traumatic Stress Disorder (PTSD) remains a significant mental health challenge, especially among veterans. A recent study published in the Journal of Contextual Behavioral Science delves into the interplay between psychological inflexibility, mindfulness, and self-compassion in the context of PTSD. The study, led by a team of researchers including Jason Luoma PhD from Portland Psychotherapy, provides critical insights into how these psychological mechanisms may influence PTSD symptoms and treatment outcomes.

Psychological Inflexibility: A Barrier to Recovery

Psychological inflexibility, a core concept in Acceptance and Commitment Therapy (ACT), is defined as the tendency to avoid or escape from uncomfortable internal experiences such as distressing thoughts, emotions, or memories and the impacts this has on people’s abilities to live according to their values and goals. This avoidance can lead to a range of maladaptive behaviors, which exacerbate PTSD symptoms rather than alleviate them. The study found that veterans with PTSD exhibited significantly higher levels of psychological inflexibility compared to those without PTSD. This finding underscores the importance of targeting psychological inflexibility in therapeutic interventions, as it may be a key barrier to recovery.

The Role of Mindfulness in Managing PTSD

Mindfulness, which involves focused and nonjudgmental attention to the present moment, has been widely promoted as a beneficial practice for managing PTSD symptoms. However, the study presents a nuanced view of how different facets of mindfulness interact with PTSD. Notably, the “observing” facet of mindfulness was associated with higher levels of PTSD symptoms, while the “describing” facet, which involves putting internal experiences into words, was linked to lower PTSD severity.

These findings suggest that not all mindfulness practices may be equally beneficial for individuals with PTSD. For example, mindfulness practices that emphasize observing one’s experiences without judgment might inadvertently increase hypervigilance or distress in some individuals with PTSD. However, practices that encourage describing and verbalizing experiences may help process trauma and reduce symptoms.

Self-Compassion: A Complex Relationship with PTSD

Self-compassion, which involves treating oneself with kindness and understanding in times of difficulty, has been found to have a generally protective effect against PTSD. However, the study’s findings complicate this narrative. While initial analyses showed that higher levels of self-compassion were associated with lower PTSD symptoms, this relationship diminished when psychological inflexibility was controlled for. This suggests that self-compassion alone may not be sufficient to counteract the effects of psychological inflexibility in individuals with PTSD.

This finding highlights the need for a more integrated approach in PTSD treatment, where self-compassion is combined with interventions aimed at reducing psychological inflexibility. Such an approach could potentially provide more robust and enduring relief from PTSD symptoms.

Implications for PTSD Treatment

The findings from this study have important implications for the treatment of PTSD, particularly among veterans. By identifying psychological inflexibility as a significant predictor of PTSD severity, the research suggests that treatments like ACT, which specifically target this inflexibility, may be particularly effective. Additionally, the nuanced understanding of mindfulness and self-compassion offered by the study can help clinicians tailor their interventions more effectively to meet the needs of their clients.

For veterans struggling with PTSD, addressing psychological inflexibility through targeted therapeutic interventions could be a crucial step toward recovery. Moreover, combining mindfulness practices that emphasize description and verbalization with self-compassion training may offer a more comprehensive approach to reducing PTSD symptoms.

Follow this link to find a pre-print version of this paper.

How Self-Criticism Impacts Emotional Responses in Social Contexts

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A recent study led by researchers from Portland Psychotherapy, including Kati Lear PhD and Jason Luoma PhD, delves into the complex relationship between self-criticism, emotional regulation, and interpersonal connections.

Published in Motivation and Emotion, this study investigates how highly self-critical people (HSCs) react to affiliative stimuli—cues that invite social bonding—and how these reactions may perpetuate feelings of social isolation.

Understanding Self-Criticism and Affiliative Stimuli

Self-criticism involves negative self-evaluation and is often employed as a self-protective mechanism to avoid rejection. However, it has been linked to interpersonal problems, such as reduced relationship satisfaction and heightened loneliness. This research tried to understand this link between self-criticism and interpersonal problems by focusing on how HSCs emotionally respond to two types of affiliative video stimuli: one intended to feeling related to caregiving and another intended to elicit feelings related to cooperative interactions.

Key Findings in Low and High Self-Criticism

The researchers observed that HSCs experienced more negative emotions, such as shame and distress, in response to both types of videos compared to people with low self-criticism (LSCs). These negative emotions were particularly pronounced in response to the caregiving video, which often elicited feelings of shame and defensiveness. Contrary to expectations, people’s self-criticism did not predict lower experiences of positive emotions like warmth, suggesting that HSCs’ challenges in social bonding may stem more from the presence of negative emotions rather than the absence of positive ones.

The Role of Expressive Suppression

In addition to experiencing more negative emotions, HSCs were more likely to use inhibit the expression of these emotion, across both video conditions. This suggests that part of how self-criticism is linked to interpersonal problems is through the tendency to inhibit the expression of emotion. Research has hiding your true emotions makes it more likely that people will feel anxious and uncomfortable around that person. The flat or masked expressions that result are often make others want to get some distance.

Implications for Therapy and Social Connection

The findings highlight the importance of addressing self-criticism in therapeutic settings. Helping HSCs process and understand their negative emotions in safe environments could be an essential step toward improving their interpersonal relationships. Interventions like group therapy or compassion-focused meditations may also help HSCs reframe their emotional experiences in response to affiliative stimuli or how to express negative emotions in an adaptive way that doesn’t cause interpersonal problems.

Conclusion

This important study by Portland Psychotherapy researchers sheds light on how self-criticism influences emotional dynamics in social situations. By understanding these patterns, therapists and clinicians can develop tailored strategies to support people struggling with self-criticism and improve their capacity for meaningful social connection. For those interested in learning more, you can access the full study in Motivation and Emotion.

Download a pre-print version of this paper here.

How Long Does Therapy Take? The Answer Might Surprise You 

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How Long Does Therapy Take? The Answer Might Surprise You

“How long until I feel better?” It’s often the first question people ask when considering therapy. And it’s a crucial one – after all, you’re investing your time, energy, and money into improving your mental health. Let me share some encouraging news about what you can expect. 

In my practice, I work with adults struggling with: 

  • Anxiety disorders 
  • Obsessive-compulsive disorder (OCD) 
  • Depression 
  • Posttraumatic stress disorder (PTSD) 

Here’s what might surprise you: most of my clients complete their treatment in just 8-20 sessions. That means meaningful change typically happens within 2-5 months – much faster than many people expect. This timeline is consistent with the typical treatment length reported in several large research studies of various types of psychological treatments¹,². 

What Makes Treatment Effective? 

Matching the Right Treatment to Your Needs 

Think of it like choosing the right tool for a specific job. Early on, we’ll work together to identify your specific challenges and select proven treatments designed for those exact issues. For instance, my clients with PTSD often benefit from a focused, 5-session program called Written Exposure Therapy³. 

The Power of Practice 

Just like learning any new skill, progress happens both in and outside our sessions. Each week, you’ll have practical exercises to try at home. These aren’t just busy work – they’re carefully chosen activities that help you build stronger coping skills. For my clients with OCD, for example, these between-session practices are often where the biggest breakthroughs happen. When implementing Exposure and Response Prevention for OCD, practicing with typically avoided situations and triggers is the primary intervention that leads to treatment progress⁴. 

Taking that first step toward therapy can feel like a big leap. But here’s the encouraging reality: positive changes often begin sooner than you might think. Even better, research shows that the progress you make in therapy tends to stick with you long after our sessions end⁵. You’re not just investing in feeling better now – you’re building skills and resilience that will serve you for years to come. 

1. Carpenter, J. K., Andrews, L. A., Witcraft, S. M., Powers, M. B., Smits, J. A., & Hofmann, S. G. (2018). Cognitive behavioral therapy for anxiety and related disorders: A meta‐analysis of randomized placebo‐controlled trials. Depression and anxiety, 35(6), 502-514.

2. Robinson, L., Delgadillo, J., & Kellett, S. (2019). The dose-response effect in routinely delivered psychological therapies: A systematic review. Psychotherapy Research, 30(1), 79–96. 

3. Sloan, D. M., Marx, B. P., Acierno, R., Messina, M., Muzzy, W., Gallagher, M. W., … & Sloan, C. (2023). Written exposure therapy vs prolonged exposure therapy in the treatment of posttraumatic stress disorder: A randomized clinical trial. JAMA psychiatry, 80(11), 1093-1100. 

4. Wheaton, M.G., Chen, S. Homework Completion in Treating Obsessive–Compulsive Disorder with Exposure and Ritual Prevention: A Review of the Empirical Literature. Cogn Ther Res 45, 236–249 (2021).  

5. von Brachel, R., Hirschfeld, G., Berner, A., Willutzki, U., Teismann, T., Cwik, J. C., … & Margraf, J. (2019). Long-term effectiveness of cognitive behavioral therapy in routine outpatient care: a 5-to 20-year follow-up study. Psychotherapy and psychosomatics, 88(4), 225-235. 

Addressing Shame in Body Dysmorphic Disorder: A Promising New Approach 

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Body Dysmorphic Disorder (BDD) is a severe mental health condition characterized by an obsessive focus on perceived flaws in one’s appearance, often leading to significant distress and impairment in daily functioning. While Cognitive Behavioral Therapy (CBT) has been the gold standard treatment for BDD, many individuals do not respond adequately to this approach. Recent research suggests that shame plays a critical role in the development and maintenance of BDD symptoms. Therefore, targeting shame directly may enhance treatment outcomes for those suffering from this debilitating disorder. 

In a pioneering study published in Behavior Modification, a team of researchers including Jason Luoma PhD, from Portland Psychotherapy, developed and tested an innovative therapeutic approach that combines Acceptance and Commitment Therapy (ACT) with compassion-focused approaches to address shame in individuals with BDD. This approach, called ACT with Compassion (ACTwC), is designed to reduce shame and self-criticism while increasing psychological flexibility and self-compassion. 

The Role of Shame in BDD 

Shame is a powerful emotion that involves seeing oneself as fundamentally flawed and unworthy. In BDD, this emotion is often tied to the perceived defects in one’s appearance, driving behaviors such as excessive mirror checking, comparing oneself to others, and social avoidance. These behaviors not only reinforce the negative self-view but also contribute to the persistence and severity of BDD symptoms. Research has consistently shown that higher levels of shame are associated with worse outcomes in BDD, including greater symptom severity, lower quality of life, and higher rates of depression. 

Despite the clear link between shame and BDD, traditional CBT does not specifically target shame, focusing instead on changing maladaptive thoughts and behaviors. The researchers recognized this gap and sought to create a treatment that would directly address the underlying shame fueling BDD symptoms. 

The ACT with Compassion Approach 

ACT with Compassion (ACTwC) integrates the principles of ACT, which encourages individuals to accept difficult emotions and commit to actions aligned with their values, with compassion-focused elements. The treatment protocol developed by the team involves 12 individual therapy sessions, each about 60 minutes long, delivered over weeks. 

The intervention includes psychoeducation about BDD and shame, mindfulness training, and experiential exercises designed to foster self-compassion and psychological flexibility. Patients are encouraged to confront and accept their feelings of shame rather than avoiding them, and to develop a kinder, more compassionate relationship with themselves. 

Promising Results from the Pilot Study 

The pilot study conducted by the researchers involved five participants diagnosed with BDD. The results were encouraging: four of the five participants showed significant reductions in BDD behaviors and self-criticism by the end of the treatment. Moreover, three participants reported decreases in body-related shame, and these improvements were maintained at a six-month follow-up. 

In addition to reductions in shame and self-criticism, participants experienced significant improvements in overall BDD symptoms, depressive symptoms, and quality of life. The treatment was well received, with participants rating it as highly credible and expressing satisfaction with the therapy. 

Implications for Future Treatment 

The findings from this study suggest that ACT with Compassion could be a promising new approach to treating BDD, particularly for individuals who struggle with intense shame and self-criticism. By directly targeting these underlying emotional drivers, this approach may offer a more effective treatment option for those who have not responded to traditional CBT. 

As with any new therapeutic approach, further research is needed to confirm these findings and to refine the treatment protocol. Larger, randomized controlled trials will be necessary to establish the efficacy of ACTwC compared to other treatments. However, the initial results are promising and suggest that this approach could help improve the lives of individuals suffering from BDD. 

You can find an open access version of this article here. 

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Portland Psychotherapy is a clinic, research & training center with a unique business model that funds scientific research. This results in a team of therapists who are exceptionally well-trained and knowledgeable about their areas of specialty.