ACT With Compassion

A number of standardized assessments exist that may be useful in working with highly self-critical and shame prone clients. These measures can be used for obtaining initial normative assessments as well as tracking change in therapy over time. Some of these measures may even have predictive utility. For example, the hated-self subscale from the Forms of Self-Criticism and Reassuring Scale seems to respond more slowly to interventions aimed at reducing self-criticism, suggesting that highly self-loathing and self-hating clients may need more time in therapy to develop self-compassion. In our practice, we often give three measures to clients at intake and periodically throughout therapy. We typically discuss the results in some detail as part of their ongoing conceptualization. These are the three we give to clients:

• Forms of Self-Criticism and Reassuring Scale (FSCRS) – last week version
• Internalized Shame Scale (ISS) – last week version
• Self-Compassion Scale (SCS-short form)

In addition, there are several other measures that can help with obtaining useful assessment information or be used to track progress:

• Functions of Self-Criticism/Attacking Scale
• Fears of Compassion Scale
• Early Memories of Warmth Scale
• Rizvi’s (2010) Shame Inventory
• Compass of Shame Scale

Other relevant measures can be found here: http://www.compassionatemind.co.uk/resources/scales.htm and www.actwithcompassion.com.

Self-report measures such as these provide useful information in terms of case conceptualization and treatment planning. How the client responds to the questionnaires informs functional analysis and helps identify important treatment targets. A client’s responses to these measures can be used at the onset of therapy to help the client and clinician join together around a common understanding of difficulties and collaboratively identify treatment goals. As therapy progresses, these measures can be used to track progress towards goals. Alternatively, if therapy seems to not be progressing as desired, using one or more of the above measures may help identify new treatment targets and/or inform a revised treatment plan or case conceptualization.

Debriefing self-report measures

While a client’s responses to self-report measures may provide useful information in and of themselves, how the client and provider debrief these measures together often elicits further information about the client’s struggles with self-criticism, shame, and self-compassion. Thus, the debriefing process can be seen not only as a way to give feedback to the client, but also as a therapeutic intervention. The following are some things to consider as you debrief any self-report measure with clients in this context.

1. Normalizing and humanizing: Individuals who are highly self-critical and shame-prone often feel incredibly isolated in their experiences of shame and self-hatred. They may walk around the world hearing their own mind’s self-attack but see others who appear very confident or self-assured. In essence, they are comparing their insides to others’ outsides. This is only made worse by the fact that a primary action tendency in shame is to hide and so they are not likely to have a lot of opportunity to learn from others that they too may struggle with self-criticism and shame. The very fact that there are self-report measures of experiences that self-critical and shame-prone clients experience communicates that they are not the only ones who experience these things. It can be very helpful for the client and therapist to be able to sit down together and look at the client’s responses in order to bring some of what has been hidden into the light. Through this process, clients can see that while not everyone struggles to the same extent they do (which itself can feel validating for clients who do struggle a great deal), they are not alone.
   
   
2. Deblaming: While debriefing a client’s responses to self-report measures can be helpful in terms of decreasing a sense of isolation, the therapist must take care so as to not minimize the unique struggle the individual is having in these areas. Clients whostruggle with profound shame and self-criticism often also feel ashamed of their own shame and ashamed of their self-criticism. The debriefing process can help the client gain some understanding of their own experience. This can be especially true when the client and therapist are able to explore together both the more quantitative self-report measures such as the ISS, FSCRS or SCS in conjunction with the more qualitative information gained from assessments such as the “Understanding Your History Related to Shame and Self Criticism” questionnaire. Using this combination of self-report scores (e.g. ISS, FSCRS, SCS) within the historical context that the more qualitative questionnaires can provide can help client and therapist together understand how the client’s self-criticism and shame-proneness makes sense given the client’s unique history.
   
   
3. Eliciting information that might not otherwise get reported: As noted above, there is often a self-perpetuating relationship between shame and self-criticism, with clients often being ashamed of their self-criticism and shame-proneness. As a result, people who are shame prone are often inclined to gloss over their tendencies to be self-critical or may not talk about what they feel shame around in any detail, or even at all. Alternately, clients may be so fused with their shame-based self-concept that they are unable to observe this pattern of thinking and feeling at all, instead simply seeing themselves as flawed, bad, weak, damaged, or inadequate. Thus, there seems to be little to report, except the consequences of this fusion with self concept; the critical thinking itself is not even noticed.  Reviewing responses to self-reports measures and, in particular, inquiring more deeply into the situations that elicit their responses can accomplish two goals: 1. To help the client step back and see shame and self-criticism as an ongoing pattern of thinking and feeling, rather than what is says it is – an immutable quality of themselves, and 2. Revealing additional detail about the contexts that elicit shame and self-criticism and the function of this behavior within those contexts.  For example, a client might endorse items on self-reports such as, “I had a sense of disgust with myself” or “I thought that others are able to see my defects” but might never have brought those up spontaneously in session. Inquiring as to when and where these thoughts occur can reveal a great deal of useful information that might otherwise never be revealed.  Functional analyses of when and where these shaming and self-critical thoughts occur can also help clients to gain a healthy distance from this type of thinking.
   
   
4. Assuming there are secrets and making space for them: Debriefing a client’s responses to self-report measures can also be a good time to talk about the important issue of “secrets” with the client. Given the action tendency to hide that is associated with shame, we recommend that the therapist discuss directly the likelihood that the client has aspects of themselves or their history they feel are so shameful they must hide them even from the therapist. In addition to past events of abuse or being humiliated, clients may also feel ashamed of times they were a perpetrator of abuse or engaged in mean or vengeful behavior.  Alternately, they may harbor secret jealousy, envy, or bitterness that they are reluctant to discuss. An acknowledgment early in therapy that secrets are expected can set the stage for more open communication between client and therapist in later sessions and also help reduce dropout related to fear and shame over unrevealed secrets. For example, the therapist might say “Research shows that people who are shame prone and self-critical often have secrets they don’t talk about with anyone. Sometimes people may have hurt another person, engaged in sexual behavior they feel shame around, or acted jealous or bitter.  Alternatively, there may be things that were done to them that they keep secret.  Secrets are expected in therapy and you don’t need to talk any you may have now, but it’s often important that they are discussed at some point in therapy. Does this make sense or you have anything you’d want to say in response to this?” This both normalizes the experience of hiding and secrecy while encouraging the client to begin to consider the possibility that at some point he or she may find it helpful to talk about even those things with the therapist.