Shame, self-criticism, self-stigma, and compassion in Acceptance and Commitment Therapy
Introduction
Empirical evidence continues to mount demonstrating the effectiveness of Acceptance and Commitment Therapy (ACT) across a wide range of conditions 1, 2, 3. In many head-to-head trials, ACT outcomes are comparable to those in more established gold-standard treatments for a particular difficulty, but only sometimes outperform those treatments 4, 5•. Thus, efforts need to shift from ‘Is ACT effective?’ to researching processes of change that may provide guidance for how to further improve outcomes. One way to improve outcomes would be to focus on new transdiagnostic processes, such as self-criticism and shame, which have been shown to play important roles in a variety of psychological disorders and issues, including depression [6], post-traumatic stress disorder [7], borderline personality disorder [8], eating disorders [9••], schizophrenia [10], addiction [11••], paranoid ideation and social anxiety, and [12] narcissistic personality disorder [13].
An important contributor to self-criticism and shame is the societal devaluation of stigmatized identities. Shame is the emotional core of the experience of stigma [11••] and tends to involve fusion with beliefs of being flawed or unlovable [14]. Self-stigma involves the internalization of a socially devalued status. Shame, the main emotional component of stigma, impedes social engagement [15], promotes interpersonal disconnection [16], and interferes with interpersonal problem solving [17]. The ashamed person's perspective is narrow, focused inward toward thoughts of a ‘bad self’ [14]. In contrast to the socially-distancing and isolating effects of shame, compassion tends to evoke more flexible ways of responding and includes behavioral repertoires around caring for and relating to self and others that are associated with affilliative emotions such as warmth, interest, sympathetic joy, and pride [18]. As such, clinical interventions targeting shame and self-criticism often focus on fostering self-compassion 19, 20, 21.
Self-compassion is fundamentally about self-to-self relating, wherein a person responds to their own behavior with the same sort of caregiving repertoire that one might apply to a friend, loved one, or other beloved person. This is a fairly complex cognitive task that requires the person to be able to observe their own behavior and respond to it in a manner that evokes these evolved caregiving repertoires. A central task of working with high self-critics is activating and cultivating these caretaking repertoires as they apply to oneself.
To date there have been a number of ACT studies looking at issues of self-criticism, shame, and self-stigma. However, with the exception of one pilot study [22••], none of this work has focused on self-compassion as a potential process variable. Below is a brief review of the existing research on ACT for shame and stigma, followed by considerations for the important role self-compassion may have in this work. Figure 1 also summarizes research examining ACT for shame and stigma, as well as research relevant to compassion in ACT.
Section snippets
Evidence supporting ACT for stigma and shame
In the past decade, several studies have examined ACT interventions for stigma and shame. Of particular relevance to treatment are several studies focused on self-stigma, or the devaluation of oneself and related fears of being stigmatized due to identification with a stigmatized group. Two studies provide support for the application of ACT for self-stigma and shame related to substance addiction. The first study [23] was an open trial that supplemented treatment as usual with a six-hour group
ACT and self-compassion
While there is growing discussion of the role of self-compassion in ACT 22••, 27 only one published study of ACT has examined compassion as a mediator of outcomes, to our knowledge. Vowles and colleagues [28••] found self-compassion to be a robust mediator of outcomes in an open trial of ACT for chronic pain. This finding is particularly interesting because the treatment did not emphasize self-compassion, raising the possibility that self-compassion may be an under-recognized mechanism of
Conclusion
Acceptance and commitment therapy successfully improves lives in a wide variety of ways. One fruitful domain for the application of ACT is in addressing self-criticism, self-stigma and shame, which are issues relevant to many people seeking treatment across a range of diagnostic categories. While self-compassion is inherent in the ACT model, there may be important ways to strengthen this process, a process which appears to be particularly important to highly self-critical and shame prone
Conflict of interest
None declared.
References and recommended reading
Papers of particular interest, published within the period of review, have been highlighted as:
• of special interest
•• of outstanding interest
Acknowledgement
The authors wish to acknowledge Dr. Jenna LeJeune for her valuable input on this manuscript.
References (33)
- et al.
Acceptance and commitment therapy for anxiety and OCD spectrum disorders: an empirical review
J Anxiety Disord
(2014) - et al.
A systematic review of randomized controlled trials of Acceptance and Commitment Therapy for adults with chronic pain: outcome domains, design quality, and efficacy
J Context Behav Sci
(2014) The efficacy of acceptance and commitment therapy: an updated systematic review and meta-analysis
Behav Res Ther
(2014)- et al.
Trauma-related shame and guilt as time-varying predictors of posttraumatic stress disorder symptoms during imagery exposure and imagery rescripting — a randomized controlled trial
Psychother Res
(2015) - et al.
Are improvements in shame and self-compassion early in eating disorders treatment associated with better patient outcomes?
Int J Eat Disord
(2014) The impact of dissociation, shame, and guilt on interpersonal relationships in chronically traumatized individuals: a pilot study
J Trauma Stress
(2010)- et al.
A pilot study and randomized controlled trial of the mindful self-compassion program
J Clin Psychol
(2013) - et al.
Self-compassion and ACT
A review of Acceptance and Commitment Therapy (ACT) empirical evidence: correlational, experimental psychopathology, component and outcome studies
Int J Psychol Psychol Ther
(2010)Acceptance and commitment therapy versus traditional cognitive behavioral therapy: a systematic review and meta-analysis of current empirical evidence
Int J Psychol Psychol Ther
(2012)
An exploration of shame, social rank and rumination in relation to depression
Pers Individ Differ
An experimental investigation of emotional reactivity and delayed emotional recovery in borderline personality disorder: the role of shame
Compr Psychiatry
Personal stigma in schizophrenia spectrum disorders: a systematic review of prevalence rates, correlates, impact and interventions
World Psychiatry
Slow and steady wins the race: a randomized clinical trial of acceptance and commitment therapy targeting shame in substance use disorders
J Consult Clin Psychol
The effect of shame and shame memories on paranoid ideation and social anxiety
Clin Psychol Psychother
Shame in patients with narcissistic personality disorder
Psychiatry Res
Cited by (101)
Racial microaggressions and trauma symptoms in a black American sample: The moderating role of self-compassion
2023, Journal of Contextual Behavioral ScienceBeyond One's Attitude Toward the Self: The Role of Social Anxiety in Self-Stigma among Individuals with Schizophrenia
2024, Journal of Nervous and Mental Disease