Why is it important to know about shame as a psychotherapist?

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My experience is that my most complex, chronic and stuck clients are often laboring under a great weight of shame. I’ve seen how shame leads them to withhold clinically useful information, how it leads to defensive and blaming behavior, and how it gets in the way of intimacy. I’ve seen how shame about their emotions, their bodies, and their thoughts impedes their self-awareness and makes it hard to be responsive to their own needs. Research also shows these observations to be true.

emotion_rock.jpgOver the past decade or more that I have been studying shame intensively, I have found that how shame functions for our clients and how it presents in the therapy room can be quite nuanced and challenging. Part of what’s tricky about shame is that the primary action tendency associated with shame is to hide. This can make it hard to recognize. Often shame works in the background, unrecognized but still motivating many of our clients’ problematic behaviors. Knowledge of how shame functions can help us to see past the defensiveness and avoidance and be able to bring light to what’s often a very dark and lonely place in which our clients find themselves stuck.

Where is the research at on shame in therapy?

There is a large body of research on how shame functions. We know that some people experience shame more easily than others. And we know that this tendency towards experiencing shame is associated with a whole host of problems, such as anger, depression, anxiety, overeating, social withdrawal, loneliness, fear of intimacy, and difficulty with experiencing compassion and self-compassion. This is just short list of many problems that have been shown to be linked to shame. What is less well developed from an empirical standpoint is how to help people struggling with chronic and pervasive shame. Shame has long been known by clinicians to be important, but has only recently been addressed by the more empirical wings of psychotherapy. At this point, the two most well-established treatments for shame are acceptance and commitment therapy and compassion-focused therapy. A handful of randomized trials and a range of open trials are giving us some new ideas on what works to help people stuck in shame. I recently published a review of the data related to ACT, shame, and compassion here. A comprehensive review of the data on CFT can be found here.

Approaching shame as a transdiagnostic process that can be integrated into a variety of clinical traditions 

From an empirical perspective, we know that shame and self-criticism play an important role in a variety of psychological difficulties including depression, post-traumatic stress disorder, borderline personality disorder, eating disorders, schizophrenia (particularly paranoia), social anxiety, and addiction. It’s appears that shame and self-criticism are transdiagnostic processes that, if targeted successfully, could improve outcomes across a range of mental health difficulties. And we are starting to see some early empirical evidence that suggests this may be the case.

If you are a therapist, you are already working with shame in your practices, whether you know it or not. This is particularly true for clinicians who work with clients experiencing more complex and chronic problems. Many of us doing that work already have a well-developed repertoire of working with shame, based on whatever perspective we are coming from. However, a more thorough understanding of what the research has to say about what shame can help therapists from all clinical traditions fine tune  the tools they already have and also offer new techniques they can integrate into their practice.

If you want to learn more about the role of shame in psychotherapy, here are some resources: