20 science-based recommendations for therapy with highly self-critical or shame-prone clients

It’s our anniversary!!! It was two years ago this month that “Team Compassion” started the ACTwithCompassion website. Over the course of those two years the number of people following our work has grown tremendously and we feel very honored and humbled that so many of you seem to have found what we are doing here helpful in some way. Thank you!

top_20_250.jpgFor the last years, Team Compassion founding member Dr. Melissa Platt has been scouring journals and the empirical literature to bring you monthly research updates. In this post, we have pulled together the 20 research findings we feel are most directly applicable to working with highly self-critical and shame prone (HSC/SP) clients. And so on our anniversary, we present to you, our top 20 science-based recommendations for working with highly self-critical and shame-prone clients!!!

20. Effective work with shame means exposure to shame. The experience of shame is so excruciating that of course it makes sense we try to avoid it. For shame prone clients, this becomes a central part of their existence, leading to lots of behavior that revolves around shame and avoiding shame. One problem with pervasive avoidance of shame is that it robs us of opportunities for learning. For example, Luoma et al. found that higher levels of shame immediately following a group treatment focused on shame predicted better outcomes four months later. This suggests that effective work with shame means bringing clients into contact with shame, while simultaneously using perspective taking and compassion-based exercises to help clients learn new ways of responding to their own shame, other than avoidance.

For more read: Luoma, J. B., & Kohlenberg, B.S., Hayes, S. C., & Fletcher, L. (2012). Slow and steady wins the race: A randomized clinical trial of Acceptance and Commitment Therapy targeting shame in substance use disorders. Journal of Consulting and Clinical Psychology, 80, 43-53.

19. It’s important to assess for past experiences of warmth and belonging, not just criticism and disconnection. Matos and colleagues found that early memories of warmth buffered the effects of shame memories on depression. Shame/criticism and warmth/responsivity are not two ends of one continuum, but rather are two separate continua and clients’ histories can be high or low on one or both of these. Carefully eliciting clients’ experiences of warmth, belonging, and connection is important in identifying resources that can then be built on to foster greater self-compassion.

For more read: Matos, M., Gouveia, J. P., & Duarte, C. (2015). Constructing a self protected against shame: The importance of warmth and safeness memories and feelings on the association between shame memories and depression. International Journal of Psychology and Psychological Therapy, 15(3), 317-335.

18. Pay attention to your expression of warmth and positive regard. Zuroff and colleagues found that higher self-critical perfectionism in clients predicted the tendency for therapists to show less warmth and positive regard. There are a couple of ways to interpret these findings. First, it could be that high self-critics trigger therapists’ threat systems more readily, thus keeping high self-critics from getting the warmth and compassion that could be beneficial to them. Alternatively, therapists of high self-critics could be implicitly matching their clients where they are at by withholding warmth. This finding makes sense in the light of other studies showing that highly self-critical clients find compassion anxiety provoking. Your expressions of compassion and support that may feel good to one client, may actually feel scary or conflicted for a highly self-critical client. It may sometimes be helpful to moderate more intense affective expressions on your part or try connecting in a casual or more “friendly” manner rather than a more intense or serious manner. We suggest assessing your client’s responses to warmth and positive regard to determine their needs and then to practice meeting them where they are at and slowly and deliberately increasing expression of warmth.

For more read: Zuroff, D.C., Shahar, G., Blatt, S.J., Kelly, A.C., & Leybman, M.J. (2016). Predictors and moderators of between-therapist and within-therapist differences in depressed outpatients' experiences of the Rogerian conditions. Journal of Counseling Psychology, 63, 162-172.

17. Use imagery exercises involving friends or children struggling with the same problem as the client. Flexible perspective taking tends to enhance self-compassion. A study of virtual reality therapy demonstrated reductions in depression and self-criticism when people were led to respond with compassion to an avatar of themselves as a child. This finding lends support to using imagery-based compassion exercises to help clients imagine themselves as a young child or a friend who is struggling with the same thing they are struggling with.

For more read: Falconer, C.J., Rovira, A., King, J.A., Gilbert, P., Antley, A., Fearon, P., Ralph, N., Slater, M. and Brewin, C.R., 2016. Embodying self-compassion within virtual reality and its effects on patients with depressionBritish Journal of Psychiatry Open2(1), pp.74-80.

16. Helping clients be kind to others may help them be kind to themselves. Work with highly self-critical clients involves not only helping them be more compassion and kind to themselves, but also bringing these values to bear on their relationships with others. Raposa and colleagues found that prosocial behavior towards others buffered the effects of stressful events. A second study by Trew and Alden found that instructing socially anxious undergrads to be kind during social interactions resulted in the largest decreases in desires to avoid social situations. It may be important here to also teach your clients mindfulness skills to help them pause and notice what they are feeling when they are engaging in acts of kindness so they don’t miss the opportunity to fully experience the intrinsic reinforcement that comes with living in line with their values.

For more read: Raposa, E. B., Laws, H. B., & Ansell, E. B. (2015). Prosocial Behavior Mitigates the Negative Effects of Stress in Everyday Life. Clinical Psychological Science.

Trew, J. L., & Alden, L. E. (2015). Kindness reduces avoidance goals in socially anxious individualsMotivation and Emotion39(6), 892-907.

15. Regret + Self-Compassion = Growth. Don’t jump too quickly to having a client move away from expressing regret and guilt. Zhang and Chen found that expressions of regret and guilt about a specific behavior can lead increases in values-based action, WHEN (and here’s the trick) those expressions of regret are met with self-compassion. So rather than trying to decrease expressions of regret, you may instead want to focus on helping clients treat themselves with compassion when they have done things they regret.

For more read: Zhang, J. W., & Chen, S. (2016). Self-Compassion Promotes Personal Improvement From Regret Experiences via Acceptance. Personality and Social Psychology Bulletin, 42(2), 244-258.

14. Pay attention to the timbre, pacing, and tone of your voice. How you say something may be just as important as what you actually say. As a highly social species, humans are highly influenced by not just the content of what people say, but also other qualities of speech like tone, pacing, and volume. Aucouturier and colleagues found that digitally altering the tone of people’s voices made them feel emotions that matched the alteration, even though participants were unaware of the alteration. This suggests that your nonverbal behavior as a therapist, including voice tone, may be extremely important, particularly with clients who are highly attuned to potential signs of disapproval or social threat.

For more read: Aucouturier, J., Johansson, P., Hall, L., Segnini, R., Mercadié, L., & Watanabe, K. (2016). Covert digital manipulation of vocal emotion alter speakers’ emotional states in a congruent direction. Proceedings of the National Academy of Sciences, 201506552.

13. Lovingkindness meditation can be a powerful and lasting antidote to self-criticism. Shown to positively impact a whole host of difficulties from PTSD and depression to migraines and emotion regulation, Lovingkindness, or Metta meditation, can be an extremely effective and versatile skill. In their randomized controlled trial with highly self-critical participants, Shahar and colleagues found that participating in a 7-week lovingkindness meditation group resulted in significant decreases in both self-criticism and depressive symptoms. In addition, these gains were maintained at 3 month follow-up. So consider using lovingkindness meditation as a skill for your HSC/SP clients to practice as homework.

For more read: Shahar, B., Szsepsenwol, O., Zilcha‐Mano, S., Haim, N., Zamir, O., Levi‐Yeshuvi, S., & Levit‐Binnun, N. (2015). A Wait‐List Randomized Controlled Trial of Loving‐Kindness Meditation Programme for Self‐Criticism. Clinical psychology & psychotherapy22(4), 346-356.

12. Highly self-critical clients often experience imagery exercises as anxiety provoking. Duarte and colleagues showed that highly self-critical people responded to an imagery exercise with anxiety and biomarkers of increased stress. HSC/SP clients may have very different experiences of and responses to imagery and meditation exercises than your non-HSC/SP clients. We aren’t suggesting that you avoid using these types of exercise, but simply be aware that these types of exercises may initially result in HSC/SP clients feeling increased threat. You may want to normalize anxiety in reaction to these exercises and also provide extra support and structure for any homeworks that involve imagery, assuming that these will probably be difficult at first.

For more read: Duarte, J., McEwan, K., Barnes, C., Gilbert, P., & Maratos, F. A. (2015). Do therapeutic imagery practices affect physiological and emotional indicators of threat in high self‐critics? Psychology and Psychotherapy: Theory, Research and Practice88(3), 270-284.

11. It’s normal to feel shame as a therapist. Since we are human too, it’s normal for therapists to feel shame and become self-critical. The study below showed that shame and embarrassment are common in psychotherapy and highlight how we, in our role as therapists, also need compassion and self-care. Being aware of our own shame and learning about it can help us to model self-compassion for our clients.

For more read: Klinger, R. S., Ladany, N., & Kulp, L. E. (2012). It’s too late to apologize: Therapist embarrassment and shame. The Counseling Psychologist, 40(4), 554-574.

10. Don’t let shame stand in the way. For many clients, stigma and shame are significant barriers to accessing mental health treatment in the first place. Consider ways to address these things before a client ever walks through your door. Look through your marketing materials, website, intake forms, signage in your office, etc. What messages are you sending about the things your potential clients may feel shame and stigma around?

For more read: Glazier, K., Wetterneck, C., Singh, S., & Williams, M. (2015). Stigma and shame as barriers to treatment for Obsessive-Compulsive and related disordersJournal of Depression and Anxiety, 4(191), 2167-1044.

9. Don’t make shame another enemy—it can serve some important functions! Shame isn’t always bad. This can be a tough one because, as therapists, it can be very painful to watch someone we care about, our client in this case, experience the suffering of shame. So it makes sense that we would have a strong urge to always work to eliminate shame. However, it does appear that in some contexts experiencing shame can actually motivate people to engage in valued behavior change. Shame displays can also elicit sympathy, cooperation, and prosocial responding from others. What seems to be most important is that we attend to the functions of shame rather than dismissing it outright as “bad”.

For more read: De Hooge, I. E., Zeelenberg, M., & Breugelmans, S. M. (2011). A functionalist account of shame-induced behaviour. Cognition & Emotion, 25(5), 939-946.

Beer, J. S., & Keltner, D. (2004). What is unique about the self-conscious emotions? Psychological Inquiry, 15, 126-129.

Martens, J. P., Tracy, J. L., & Shariff, A. F. (2012). Status signals: Adaptive benefits of displaying and observing the nonverbal expressions of pride and shame. Cognition & Emotion26(3), 390-406.

8. Physical warmth can help us to access emotional warmth. The threat systems of highly self-critical people are chronically engaged, while their social safety systems are under activated. And since (see above) more direct expressions of emotional warmth or connection might, for some HSC/SP folks, actually end up feeling more threatening, you might consider other ways to help these clients engage their soothing system, such as through physical warmth (think a cozy office, a cup of warm tea, or a comfortable blanket). Bargh et al. conducted a series of studies showing that physical warmth is connected to feelings of emotional or social warmth. Using physical warmth may be especially helpful as you start introducing other relational models for connection and compassion that might otherwise elicit shame or fear.

For more read: Bargh, J. A., & Shalev, I. (2012). The substitutability of physical and social warmth in daily life. Emotion, 12(1), 154.

7. Nonverbal signs of shame may be more reliable than self-reports. Randles and Tracy found that nonverbal signs of shame, but not verbal reports of shame, predicted subsequent tendencies to relapse among people attending Alcoholics Anonymous. Clinically, we’ve observed that clients experiencing shame may not even report that they experience high levels of shame or self-criticism. Shame is not a very commonly discussed emotion and people often have little language to describe the experience. As a result, it’s important to not just rely on the client’s self-report of how self-critical or shame prone they feel they are. Therapists need to be sensitive to and inquire about nonverbal displays of shame as those are often a better indicator of when shame may be at work.

For more read: Randles, D., & Tracy, J. L. (2013). Nonverbal displays of shame predict relapse and declining health in recovering alcoholics. Clinical Psychological Science,1(2), 149-155.

6. Working with shame is central for many people with PTSD. It probably does not come as a surprise that individuals who have a trauma history also tend to experience high levels of shame. Research shows that the impact of shame on those with a trauma history seems to be particularly important. Thus, when working with individuals who have experienced trauma, it is essential to also assess for and address any accompanying shame they may be experiencing.

For more read: Lawrence, V. A., & Lee, D. (2014). An exploration of people's experiences of compassion‐focused therapy for trauma using interpretative phenomenological analysis. Clinical Psychology & Psychotherapy, 21(6), 495-507.

Freed, S., & D’Andrea, W. (2015). Autonomic arousal and emotion in victims of interpersonal violence: shame proneness but not anxiety predicts vagal toneJournal of Trauma & Dissociation16(4), 367-383.

Schoenleber, M., Sippel, L. M., Jakupcak, M., & Tull, M. T. (2015). Role of trait shame in the association between posttraumatic stress and aggression among men with a history of interpersonal trauma. Psychological Trauma: Theory, Research, Practice, and Policy, 7(1), 43.

5. Say it plainly. Duffy and colleagues found that more technical or clinical ways of speaking resulted in higher levels of shame and guilt in their sample of clients. So, keep it casual and more common sense—remember, you’re trying to help them connect with the universality of suffering and help them see that they aren’t alone.

For more read: Duffy, M. E., & Henkel, K. E. (2015). Non-specific terminology: Moderating shame and guilt in eating disordersEating Disorders, 1-13.

4. Guilt ≠ Shame. Shame and guilt appear to function differently for people. While neither is always “good” or “bad”, it may be important to differentiate in your case conceptualization between a client’s experience of guilt and that of shame as you may want to have a different approach to these distinct phenomena. It may also be helpful for clients to be able to make the distinction between feeling ashamed and feeling guilty.

For more read: Scott, L. N., Stepp, S. D., Hallquist, M. N., Whalen, D. J., Wright, A. G., & Pilkonis, P. A. (2015). Daily shame and hostile irritability in adolescent girls with borderline personality disorder symptoms. Personality Disorders: Theory, Research, and Treatment, 6(1), 53.

Stuewig, J., Tangney, J. P., Kendall, S., Folk, J. B., Meyer, C. R., & Dearing, R. L. (2015). Children’s proneness to shame and guilt predict risky and illegal behaviors in young adulthoodChild Psychiatry & Human Development46(2), 217-227.

Rodriguez, L. M., Young, C. M., Neighbors, C., Campbell, M. T., & Lu, Q. (2015). Evaluating guilt and shame in an expressive writing alcohol interventionAlcohol49(5), 491-498.

3. Self-Compassion is helpful for social stressors. Breines and colleagues found that people higher in self-compassion were less stressed by a public speaking task than those low in self-compassion, even after controlling for self-esteem. Self-compassion work may be a helpful tool to cope with not only in traumatic or highly intense stress or shame, but also those day-to-day stressors that we often encounter, especially when those stressors are interpersonal in nature, such as social anxiety, fear of rejection, or fears evaluation from others.

For more read: Breines, J.G., McInnis, C.M., Kuras, Y.I., Thoma, M.V., Gianferante, D., Hanlin, L., Chen, X. & Rohleder, N., 2015. Self-compassionate young adults show lower salivary alpha-amylase responses to repeated psychosocial stressSelf and Identity14(4), pp.390-402.

2. It’s ok to have low self-esteem. Focus on boosting your client’s self-compassion rather than their self-esteem. Research consistently shows that efforts to boost self-esteem have, at best, very limited positive benefits. Sometimes high self-esteem is even associated with negative side effects. In addition, at least one longtiduinal study shows that the negative associations typically found between low self-esteem and negative mental health were buffered by high self-compassion.

For more read: Baumeister, R. F., Campbell, J. D., Krueger, J. I., & Vohs, K. D. (2003). Does high self-esteem cause better performance, interpersonal success, happiness, or healthier lifestyles? Psychological science in the public interest4(1), 1-44.

Marshall, S. L., Parker, P. D., Ciarrochi, J., Sahdra, B., Jackson, C. J., & Heaven, P. C. (2015). Self-compassion protects against the negative effects of low self-esteem: A longitudinal study in a large adolescent sample. Personality and Individual Differences, 74, 116-121.

And our #1 science-based recommendation for therapists working with highly self-critical and shame-prone clients…

1. Love your own self-doubt; it makes you a better therapist. Therapists who endorse higher levels of self-doubt in their clinical work actually had better client outcomes than therapists who experience low levels of self-doubt, especially when self-doubting was accompanied by positive self-affiliation (i.e. self-love). So when you are doubting yourself as a therapist, make sure you are following the recommendations you give your clients and extend yourself some self-compassion.

For more read: Nissen‐Lie, H. A., Rønnestad, M. H., Høglend, P. A., Havik, O. E., Solbakken, O. A., Stiles, T. C., & Monsen, J. T. (2015). Love Yourself as a Person, Doubt Yourself as a Therapist? Clinical Psychology & Psychotherapy.

 

Resources for learning more:

If you're looking for a good starting point to learn more about how to work with shame in therapy, in addition to the resources on our website, I'd recommend the book, Shame in the Therapy Hour, which gives an overview of how to work with shame from a variety of different perspectives. 


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