ACT With Compassion

We have written up some of our thinking to accompany last week’s Tool of the Month - Exploring the Past - Shame and Self-Criticism.

One of the first steps in case conceptualization with shame-prone and self-critical clients is to assess their relational history with shaming/criticizing and compassionate/caring others. As mentioned in our previous blog post, understanding clients’ relational history can help remove blame and may also help to begin defusion from self-critical “programming.”

We will focus on exploring early experiences with shame and criticism in this month’s post, and then turn to early experiences with compassion next month. In this first part of the case conceptualization, the therapist explores for key relationships and events that contributed to the client’s current self-criticism and shame. Some clients may find this history taking highly aversive, and so this process may take some time to unfold. Many clients have a relatively poor recall of events that may contribute to their shame and self-criticism. Some important relationships and key events may only come to light in the later stages of therapy. These specific events elicited in later phases of therapy can subsequently be added to the list of key relationships and events when they are discovered. In this way, it is important to recognize that case conceptualization process is a dynamic, ongoing process, rather than some static rubric that remains unchanged throughout therapy. Regardless of the speed with which the process unfolds, it is usually important to gently and compassionately elicit these events so that the therapist can play the role of the compassionate observer of the clients report, validating their experience of the events described. Through this process, the client has the opportunity to learn to re-view their own experiences with more compassion via seeing the experiences through the eyes of another who validates and verbally reflects a more compassionate perspective. Often, this will be the first time that the client has experienced someone listen to their hurts, hopes, losses, and pains with kindness and non-judgment.

Initially, the case conceptualization may focus mostly on identifying what these key historical events were and some limited amount of information about how these impacted the person. Often, it is only later in therapy that the groundwork has been laid to revisit these memories from a perspective that will allow for some new way of interacting with them, so that learning can occur.

Key events to look for during the exploration process include experiences of sexual, physical or verbal abuse, trauma, neglect, or bullying. These may be one-time events that had a powerful impact on the person, or they may instead be repeated, in which case they may be more nested inside a relationship context. Often times, single events that involve some violation of the person’s sense of self or extreme forms of humiliation can have profound effects over time, particularly if they were not discussed or otherwise processed in a supportive context. For example, survivors of a single sexual assault may become particularly shame prone if they are in some way made to believe that it is not okay to talk about the event, or if disclosure is met with disbelief, retaliation, or invalidation of one’s emotional reactions. A single non-traumatic event involving feelings of exposure may also lead to shame proneness and self-criticism. An example is being called a name and laughed at by peers, especially if such an event is also linked with social disconnection and isolation.

In addition to some of these formative events, an exploration of the individual’s key attachment relationships can also provide critical information for understanding how the person developed their current patterns of relating to self and other. In particular, it can be important to explore whether the person felt that key attachment figures expressed warmth and caring to them. One need not have a history of extreme levels of abuse or verbal criticism from others in order to develop a shame prone and self-critical tendency. Because of the mind’s tendency towards negativity, the mere absence of warm and loving communications and physical contact from attachment figures can alone result in an individual developing a more self-critical and shame prone stance towards themselves. Questions to assess this are  “How did this person respond to you when you were distressed? Did they soothe you or validate your experiences?

It is important to note whether their primary caregiver(s) were consistent and predicable in their warmth, criticism, or detachment, or whether they were hard to predict. Caregivers who were predictably cold may lead to the development of predictable styles of self-to-self relating (e.g., consistently self-criticizing). On the other hand, caregivers who were sometimes warm, and other times harsh and attacking are more likely to lead to more varied and dissociative self-to-self (to self to self) relating. In addition to questions about the warmth and caring an individual felt, it is also important to explore how differences between a child and her or his attachment figures’ emotions, wants, needs, and interests were addressed. When they were sad would their caregiver recognize, “Hey, you are sad right now. It’s okay. I’m here,” and give them a big hug? Would they ignore their sadness? Would they punish it by mocking them or saying, “Stop crying!” When their caregiver confuse their own emotions for the client’s emotions? Were certain emotions more or less acceptable or discouraged compared to others?

People who experience significant amounts of shame often frame relationships in terms of hierarchy. Interpersonal interactions are understood in terms of one person being in the dominant role and the other in the submissive role. This is in contrast to more egalitarian and affiliative ways of viewing relationships. Thus, shame prone clients may alternate between attempts to be dominant and adopting a more submissive position. In understanding these struggles for a sense of control and agency in relationships as an adult, it can be important to explore whether, as a child, differences in what he or she wanted or was interested in and the wants and interests of his or her attachment figures were met with a warm and accepting stance from the attachment figure or whether the attachment figure tended to make their desires dominant and be dismissive of the child’s needs or wants. Some questions to assess this are, “What happened when you wanted something that your parent didn’t want you to have?” “Did your parents show enthusiasm and excitement for the things that you were inherently interested in? Or did you feel like they had expectations of what you should want and who should be that you need to live up to?”

A core part of this process is developing a coherent, non-shamed-based narrative for why the person responds in the way that they do, and why they feel so inadequate and/or self hating. A key message is that the client is not responsible for having these thoughts about themselves and that this more  negative view of themselves is the understandable learned response from a particular learning history. The therapist’s job is to validate that it is understandable, and in fact inevitable, that the client has this view of herself or himself given the events and relationships described. Thus, while the therapist does not agree with the evaluations of the self-critical mind that the person is damaged, broken, or somehow shameful, the therapist does take the position that it is completely understandable that the individual’s mind would be programmed to produce such thinking.