Addressing Shame Through Self Compassion

Abstract

Shame is a common experience for individuals living with chronic diseases related to lifestyle, such as obesity and diabetes. It is often characterized by feelings of stigma and worthlessness, leading many patients to feel judged and unworthy of respect, which can profoundly affect health outcomes and overall quality of life. Despite the severe consequences of shame, therapeutic approaches to address it remain underexplored. This paper highlights the role of Acceptance and Commitment Therapy and Compassion Focused Therapy as effective strategies to mitigate shame, cultivate self-compassion, and, therefore, enhance health outcomes for individuals with chronic lifestyle-related conditions. These therapies have demonstrated positive effects on treatment adherence and self-management among patients with chronic diseases. Therefore, healthcare providers can improve patients’ overall well-being by adopting strategies from these therapies, such as using compassionate language that emphasizes empathy, non-judgmental support, and validation, all of which help reduce shame and stigma.

“Active listening can help healthcare providers detect self-criticism.”

Introduction

Shame is a prevalent experience for individuals living with chronic diseases associated with lifestyle factors, such as obesity and diabetes. In the lifestyle medicine literature, shame is often discussed as feelings of stigma and worthlessness. ¹ Many patients with these conditions report feeling constantly judged and undeserving of respect. These feelings of shame, as discussed by Adams, Enichen, Demmig-Adams ² in this issue, can have a profound impact on health outcomes and overall quality of life.^1,3,4 Given these emotional burdens, it is crucial to understand how shame influences the well-being of these individuals and address it as part of their care.

Although many individuals experience feelings of shame and the consequences associated with it are severe, ways to address this in a therapeutic context are understudied. ⁵ The use of Acceptance and Compassion Therapy (ACT) and Compassion Focused Therapy (CFT) provide ways to address feelings of shame directly and have been shown to be important treatment components for patients.^6,7 Specifically, ACT and CFT have clearly demonstrated improvement to outcomes associated with adherence and self-management. ⁸ In this paper, we will describe how these therapeutic techniques can be effectively utilized to mitigate shame, foster self-compassion, and ultimately improve health outcomes for individuals with chronic lifestyle-related conditions.

Shame and Self-Criticism

Shame is a painful feeling of humiliation caused by the realization of engagement in wrong or socially inappropriate behavior. It commonly includes the perception of being judged by others for a conscious flaw, whether that judgment is actual, potential, or imagined.^9,10 A dichotomy exists surrounding the role of shame. Some evidence suggests that it fulfills a functional purpose, facilitating behavior change by encouraging self-regulation; whereas, other evidence points to shame having deleterious effects. ¹¹ From a functional perspective, shame can be adaptive, fostering social cohesion and ethical behavior. ¹² Unfortunately, the functional aspect of shame may also incorrectly drive people to chronically shame others. For instance, parents may use language with their children (e.g., weight-related teasing) with good intentions, aiming to motivate their children to adopt healthier habits. This approach is often based on the belief that shame, which helped the parents self-regulate, can also drive positive change in their children.^13,14 Clearly, shaming children is not a recommended parenting practice, but some parents are likely using it based on the idea that it can be functional. Ultimately, it is beyond the scope of this manuscript to discuss the reasons that shaming is commonplace for those who suffer from obesity and other related diseases; however, shame often transitions from something that can be functional into a factor that supports dysfunction. Specifically, the prolonged presence of shame is extremely likely to lead to adverse psychological and physical health repercussions. ⁹

Chronic shame, characterized by persistent feelings of inadequacy, can exert lasting detrimental impacts on both mental and physical health. ¹¹ Chronic shame erodes an individual’s capacity for self-care and significantly hinders health behaviors. ¹⁵ For example, rather than inspiring healthy behaviors, shame leads to social isolation and psychological disorders, including depression or anxiety. ¹⁶ Specifically in the context of diabetes, shame leads to poor management of the condition, such as neglecting blood sugar monitoring or avoiding necessary medical care, ultimately worsening health outcomes. ¹⁷ This intensifies health challenges rather than alleviating them, perpetuating a cycle of distressing behaviors that undermine a patient’s condition. ⁹

Self-Compassion

Self-compassion is the ability to acknowledge one’s mistakes with kindness and understanding, which help to address feelings of discouragement, self-criticism, and unhealthy coping mechanisms. ¹⁸ Facilitating feelings of self-compassion has been shown to be effective in mitigating the detrimental impacts of chronic shame, support emotional regulation, and increase the likelihood of long-term change in health and well-being. ¹⁹ It is associated with resilience, better stress regulation, health-promoting behaviors, and intrinsic motivation.^20-22 Conceptually, self-compassion assists individuals in developing internal care for themselves which is associated with behavior changes that can have a significant impact on physical health. ²⁰

Compassion-based therapies were originally developed to cultivate sensitivity to suffering in self and others with a desire to prevent and alleviate it. For instance, Compassion Focused Therapy (CFT) is developed to target self-criticism and shame that underpin anxiety and depression. ²³ Because of its ability to address these issues in mental health, it has been adapted to be used with individuals who experience shame due to chronic health conditions. CFT has demonstrated promising results, such as reduced body weight shame, improved self-compassion in individuals who have obesity and type 2 diabetes.^24-26 CFT encompasses several core components aimed at fostering compassion for one’s self and others. ²³ It incorporates mindfulness-based practices to promote present-moment awareness and non-judgmental acceptance of thoughts and feelings. CFT emphasizes understanding the origins and functions of self-criticism, enabling individuals to recognize these thoughts as defense mechanisms. It encourages tolerating difficult emotions without avoidance, cultivating self-compassion through kindness and understanding during challenging times. Given its effectiveness in reducing shame and improving self-compassion, ²⁷ CFT offers a practical approach for clinicians to address both the psychological and emotional challenges faced by individuals with chronic health conditions.

Acceptance and Commitment Therapy (ACT) is another technique that targets and promotes psychological flexibility enabling distress tolerance.^28,29 ACT focuses on six core processes to enhance psychological flexibility. These include cognitive defusion, which helps individuals detach from unhelpful thoughts, and acceptance, which encourages embracing difficult emotions rather than avoiding them. Present-moment awareness fosters mindfulness and non-judgmental attention to current experiences, while self-as-context helps individuals recognize they are more than their thoughts and feelings. ACT also emphasizes values clarification to guide meaningful action, and committed action, which involves taking steps aligned with personal values despite challenges. Focusing on individuals who have obesity, a systematic review clearly demonstrated that ACT can enhance psychological well-being, decrease psychological distress, address weight-related stigma, and decrease body dissatisfaction and self-criticism. ³⁰ ACT has been shown to effectively improve lifestyle in colorectal cancer survivors, ³¹ glucose control and self-management behaviors in individuals who have diabetes, ³² and diet and physical activity in patients with cardiac issues. ³³ Additionally, ACT has shown promising results in supporting overall quality of life and treatment adherence. ³⁴ All of these outcomes demonstrate that the inclusion of techniques that address shame and self-criticism can have a substantial impact on patients’ physical and mental health.

Conclusion

Chronic shame not only subverts confidence, but it can also cause a patient to devalue caring for themselves. Addressing the self-criticism and shame that so many of our patients are experiencing is likely to support healthy behavior change in a variety of ways. This can be accomplished through therapeutic techniques (CFT and ACT). Consistent with these techniques, the use of compassionate language characterized by empathy, non-judgmental support, and validation can reduce feelings of shame and stigma in patients, thereby improving their emotional well-being and increasing treatment adherence. An underlying concept in these therapies is promoting an individual’s ability to tolerate distress and meet internal feelings of shame with compassion. Active listening can help healthcare providers detect self-criticism. To address self-criticism, we should guide patients to better tolerate the distress it causes and model a compassionate response to feelings of shame. Giving patients the skills to demonstrate kindness to themselves and engage in self-compassion provides an optimal internal environment in which to address significant health issues.