A Comprehensive Review of Generalized Shame Measures: What Clinicians and Researchers Need to Know 

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Shame is a complex, self-conscious emotion that plays a significant role in both social functioning and psychological well-being. While shame can be a healthy response in certain contexts, chronic and intense feelings of shame have been linked to a variety of mental health issues, including depression, post-traumatic stress disorder (PTSD), and substance misuse. Given the profound impact of shame on mental health, the need for reliable and valid measures of this emotion is paramount. A recent systematic review, conducted by a team of researchers including Kati Lear, PhD and Jason Luoma, PhD from Portland Psychotherapy, offers valuable insights into the current state of self-report measures of generalized shame. 

The Complexity of Measuring Shame 

Shame is not a straightforward emotion to assess. It encompasses a wide range of experiences, from a fleeting twinge of self-consciousness to a deeply ingrained sense of personal failure. This complexity is reflected in the variety of approaches researchers have taken to measure shame. Some measures focus on the frequency and intensity of shame-related emotions, while others assess how likely individuals are to experience shame in hypothetical situations. 

This review highlights the diverse conceptualizations of shame, noting that it can manifest as both an emotional reaction to how one sees themself (internalized shame) and how one perceives themself to be viewed by others (external shame). This dual nature of shame adds another layer of complexity to its measurement, with some tools focusing on internalized shame, others on external shame, and a few attempting to capture both dimensions. 

Strengths and Limitations of Existing Measures 

The review identified 19 different self-report measures of generalized shame, each with its own strengths and limitations. While some measures, such as the Internalized Shame Scale (ISS) and the Test of Self-Conscious Affect (TOSCA), are widely used and have shown promising psychometric properties, the review found that none of the existing measures fully meet the criteria for recommended use based on the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines. 

One of the key challenges identified in the review is the lack of studies assessing the development and content validity of these measures. Content validity, which refers to how well a measure captures all aspects of the construct it intends to assess, is particularly important for complex emotions like shame. However, the review found that many measures lacked comprehensive development studies, and those that did exist often had methodological shortcomings. 

Another significant issue is the difficulty distinguishing between shame and closely related emotions like guilt. While some measures attempt to separate these emotions, the review notes that this distinction is not always clear in practice. This overlap can complicate the interpretation of results and may limit the utility of certain measures in clinical settings. 

Implications for Clinical Practice 

For clinicians, the review’s findings underscore the importance of selecting shame measures with intention. While generalized shame measures can provide valuable insights, they may not always capture the specific aspects of shame that are most relevant to a particular client or context. For example, scenario-based measures, which assess how individuals might respond to hypothetical situations, may be more useful for understanding how shame manifests in specific contexts, whereas experience-based measures, which assess the frequency of shame-related emotions, might be better suited for tracking changes in shame over time. 

The review also highlights the potential benefits of using multidimensional measures that assess different components of shame separately. For instance, distinguishing between internal and external shame could help clinicians better understand the specific triggers and consequences of a client’s shame, allowing for more targeted interventions. 

Moving Forward: Recommendations for Future Research 

This systematic review provides a clear roadmap for future research on shame measures. The authors call for more rigorous development and validation studies, particularly those that include diverse populations and examine the cross-cultural validity of shame measures. They also suggest that future research should focus on creating measures that can reliably distinguish between shame and related constructs, such as guilt and self-criticism. 

Additionally, the review points to the need for measures that can assess the impact of clinical interventions on shame. While some existing measures have shown promise in this area, more work is needed to establish their responsiveness to change, particularly in clinical populations. 

In conclusion, while the field of shame measurement has made significant strides, there is still much work to be done. By addressing the gaps identified in this review, researchers can develop more reliable and valid tools for assessing shame, ultimately improving our understanding of this complex emotion and its role in mental health. For clinicians, this review offers valuable guidance on selecting and using shame measures in practice, helping to ensure that clients receive the most effective and personalized care possible. 

You can find the full pre-print text here.

Exploring the Efficacy of ACT-Informed Exposure for Excoriation Disorder: A New Approach in Treatment  

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Excoriation Disorder (ExD), commonly known as skin picking disorder, presents significant challenges for those who suffer from it, often leading to severe distress and self-consciousness about their appearance. Traditional treatments, like Habit Reversal Training (HRT), have shown effectiveness in managing symptoms, but there is a growing interest in exploring how additional therapeutic approaches might enhance outcomes. A study by Brian L. Thompson, PhD, from Portland Psychotherapy, investigated the potential of using exposure therapy guided by acceptance and commitment therapy (ACT)  as an adjunct to HRT for treating ExD.  

The Study Design and Approach  

The study employed a nonconcurrent multiple baseline design, a method that allows for analysis of individual participants over time. Four participants with ExD were recruited and randomly assigned to two conditions: one group received HRT followed by exposure therapy, while the other group received exposure therapy first, followed by HRT. During the ACT-informed exposure therapy phase, participants were oriented to the ACT model. They then practiced deliberately triggering urges to pick while being open and present with these urges, and then flexibly expanding their awareness of other sense perceptions (e.g., touch, taste, sight, sound, smell). The goal was not symptom reduction, as in traditional exposure, but of flexible responding to urges while not engaging in picking behavior. This design was chosen to assess whether exposure therapy, when informed by ACT principles, could improve psychological flexibility and reduce the severity of skin-picking behavior beyond what HRT alone could achieve.  

Key Findings 

The results of this study highlight several important outcomes. Results provided further evidence that HRT is effective in reducing the frequency of skin picking across participants. These findings align with previous research and supports HRT as a first-line treatment for ExD. However, the addition of ACT-informed exposure therapy yielded mixed results. While some participants reported further reductions in skin picking during the exposure phase, these reductions were generally smaller compared to those observed during the HRT phase. For example, participants who underwent exposure therapy first experienced greater reductions in skin picking during the subsequent HRT phase than during the initial exposure phase.  

One of the study’s key aims was to determine if ACT-informed exposure could enhance psychological flexibility—a core process in ACT that involves accepting internal experiences while committing to actions that align with one’s values. Contrary to the researchers’ expectations, the exposure phase did not consistently lead to improvements in psychological flexibility across participants. This finding suggests that while exposure therapy might have some utility as a secondary treatment, it may not be as effective in fostering psychological flexibility as hypothesized, or psychological flexibility is less relevant as a process of change in people who struggle with skin picking. As the experimenter used broad measures of psychological flexibility, it is also possible the measures were too general and not specific enough to picking.  

Implications for Treatment  

Despite the mixed results, the study offers valuable insights into the treatment of ExD. All participants maintained their gains at a three-month follow-up, indicating that both HRT and ACT-informed exposure have lasting effects on symptom reduction. However, the study also raises questions about the specific role that exposure therapy should play in treating ExD. Given that HRT resulted in more robust improvements than exposure therapy, this research suggests that exposure therapy might be more effective when used as a secondary intervention.  

Participant feedback indicated that exposure was an acceptable treatment. Participants who began with exposure felt that exposure therapy helped them prepare for the strategies in HRT. Some participants even endorsed a preference for exposure. For example, one participant described exposure as “more helpful overall,” and another noted that “exposure has been what really accelerated” their progress. These subjective reports highlight the potential of ACT-informed exposure to complement HRT by increasing participants’ awareness and acceptance of their urges, which might help reduce relapse rates in the long term.  

Conclusion  

This study, represents a pioneering effort to integrate ACT-informed exposure therapy into the treatment of Excoriation Disorder. It is also the first published experimental study of the use of exposure in treating skin picking. While the findings do not support exposure therapy as a robust standalone treatment, they suggest it may be a useful adjunct to HRT to help people further manage picking behavior. With skin picking, any additional improvements in reducing picking may be meaningful.  

As the field of mental health continues to explore transdiagnostic approaches—therapies that can be applied across different disorders—the integration of ACT with traditional behavioral interventions like exposure therapy offers a promising avenue for future research. The protocol is relatively simple to implement, especially for therapists familiar with exposure therapy. This study underscores the importance of tailoring treatment to the individual, recognizing that while HRT remains the gold standard for ExD, there is room to enhance its efficacy through the thoughtful incorporation of exposure therapy.  

Moving forward, larger-scale studies are necessary to determine if combining HRT and exposure therapy is more effective than HRT alone. For clinicians and researchers alike, this study offers a steppingstone toward enhancing treatments for those suffering from Excoriation Disorder and other body focused repetitive behaviors.  

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

  

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.

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