Portland Psychotherapy

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.

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. 

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/

Reducing Stigma Associated with Substance Use and Criminal Involvement

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Stigma creates significant barriers to accessing addiction treatment within the criminal legal system. New research led by Dr. Kelly Moore, and including Portland Psychotherapy’s Jason Luoma, PhD, aims to address this issue by testing a multi-level intervention called CSTARR (Combatting Stigma to Aid Reentry and Recovery). CSTARR involves training for criminal legal system staff to reduce stigmatizing attitudes and group therapy using Acceptance and Commitment Therapy (ACT) for clients to cope with self-stigma.  

The CSTARR staff training focuses on substance use and criminal involvement stigma. It teaches skills for interacting with clients in a more validating way and facilitates contact with a person in recovery who shares their experiences. This is meant to improve staff attitudes and behaviors that can undermine treatment. The ACT groups help clients accept difficult thoughts and feelings stemming from stigma and build skills for staying engaged in meaningful activities despite stigma stressors. 

CSTARR is being tested in Tennessee across court, probation, and treatment staff working with shared clients in a drug recovery court program. Around 70 staff will complete the training and 70 of their mutual clients will engage in the ACT groups. The study will look at how feasible it is to implement CSTARR in real-world legal settings. It will also gather initial data on whether CSTARR impacts important outcomes.   

For staff, the research will analyze if the training changes stigmatizing attitudes, beliefs about treatment, and social distancing from people with criminal records. For clients, it will evaluate whether ACT reduces self-stigma, shame, and isolation while improving efficacy and coping skills. At the systems level, the study will look at impacts on client retention in mandated treatment and legal infractions during the program. 

The results will inform revisions to the CSTARR manual and survey measures. They will also provide key insights into implementing multi-level stigma reduction in criminal legal settings. This research addresses an important gap, as most existing interventions have not focused on substance use and criminal involvement stigma simultaneously or been designed for legal contexts.  

The criminal legal system presents unique challenges for stigma reduction that require creative solutions. People involved in the criminal legal system often face compounded stigma, yet legal settings have historically perpetuated stigmatizing attitudes. Initiatives like CSTARR that recognize the harm of stigma and include contact with people who have lived experience have promise for making these systems more just.  

We are eager to see the results of this groundbreaking work by Dr. Moore and our colleague Dr. Luoma. Findings will elucidate strategies for reducing stigma among staff and clients in incarceration diversion programs. They will also demonstrate whether multi-level approaches that target stigma at public and self-levels can improve legal and recovery outcomes. We hope this spurs broader interest in dismantling unjust societal stigma and increasing access to unbiased, compassionate addiction care. 

Read the full 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.