Counseling Tags

Counseling Tags

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.

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 

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. 

There’s no Shame in Having OCD – Addressing Shame in OCD Treatment

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Shame is all too common among people with obsessive-compulsive disorder (OCD). Almost every person who I have worked with has expressed feeling ashamed and embarrassed about the content of their intrusive thoughts or the nature of the compulsions they engage in to combat them. This has been true for my clients whether they have been struggling with obsessions about contamination, self-harm, relationships, or something else. A common question I hear is “Why can’t I do X, Y, or Z like a ‘normal person’?” Along with such questions usually comes a barrage of self-critical thoughts like, “I’m such a weirdo” or “I’m so weak for repeatedly giving in to my intrusive thoughts.” In addition, it certainly doesn’t help to hear friends, family, and strangers – even if unintentionally – belittle your struggle when they talk about “being so OCD” as if this were a punchline.

Hopefully you are already well aware that highly effective, evidence-based treatments for OCD exist (e.g., Exposure and Response Prevention, Cognitive Behavioral Therapy, Acceptance and Commitment Therapy)and are provided by our expert clinicians in the Portland Psychotherapy Anxiety Clinic. A lesser known component of these treatments is that they often involve an explicit focus on developing skills to more effectively respond to shame and self-criticism. Below are two examples of how evidence-based OCD treatments might address shame and self-criticism related to OCD, including links to helpful resources.

ADDRESSING SHAME VIA ENHANCING SELF-COMPASSION

People, including individuals with OCD, are often naturally skillful at acting compassionately towards others. However, it can be much harder to turn that compassion inwards. Therapeutic approaches to enhancing self-compassion include learning about self-compassion, understanding how it operates in your own life, and developing a consistent self-compassion routine via practicing self-compassion-focused exercises. To learn more about self-compassion and to see example exercises, use the following links:

ADDRESSING SHAME VIA COMBATING OCD STIGMA & MISINFORMATION

The reality is that most people’s understanding of OCD is limited to media caricatures they have seen of people who are highly perfectionistic and/or extremely focused on cleanliness. One of the most common initial tasks of OCD treatment is to dispel common myths about OCD and provide more factual information. Whenever possible, I like to incorporate individuals’ main support systems in this “de-mystifying OCD” process. It becomes easier to feel less ashamed about OCD when you and the people around you understand OCD and feel like you’re on the same team in treating it. For folks who encounter OCD-related stigma especially frequently, treatment may also involve learning and rehearsing ways to practice self-advocacy. Lastly, people often find it helpful to develop a sense of community in order to feel less isolated and alone in their struggles with OCD. To learn more about OCD and to see example exercises and resources, use the following links:

https://iocdf.org/about-ocd/

https://iocdf.org/realocd/

https://iocdf.org/programs/conferences/

What Makes Us Unique

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.