5/5/2013

An ACT of Compassion:
Acceptance and Commitment Therapy as an
Intervention for Chronic and Persistent Shame
Jason Luoma, Ph.D.
Jenna LeJeune, Ph.D.

Purposes of the Workshop

To make the hidden, ubiquitous process of
evaluation and classification apparent -- in our
interactions with ourselves and others.
To help you be more sensitive to signs of shame
in your clients and yourself
To give you a experiential understanding of the
ACT theory of self
To help you to be gentler and bolder with
yourself and your clients in regards to shame
and self-compassion
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Outline
Part 1: Shame, evaluation, and classification
Part 2: The ACT model of self
Part 3: Practicing/experiencing selfcompassion

Learning through experience

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Why structure the workshop this way?

Therapy is a discussion between two people, one of
whom is more anxious than the other, and it's not
always clear who that is."
---Harry Stack Sullivan

Why structure the workshop this way?

Because ACT assumes that humans playing the role
of therapist are not fundamentally different than
humans playing the role of client
We get stuck in many of the same traps that our
clients do (since were also humans)
Thus, to maximize our ability to help, we need to
understand these traps experientially, not just
through book learning
Compassion for others is intimately tied to
compassion for yourself
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Informed Consent
Some of this will be experiential
Confidentiality
Its your choice to participate, some will do
their work privately
You are encouraged to try it on
7

Part 1
Shame, evaluation, and
classification

5/5/2013

Question for small group

discussion
What did you notice about be asked to put
each person into two categories during their
introduction?
How did it feel to put people into categories?
How did it feel to introduce yourself knowing
that others were thinking of categories to put
you in?

Small group exercise

1) Complete the self-compassion measure on
your own
2) Discuss in small groups: What did you notice
about yourself? Did you get any ideas about
how you might want to treat yourself
differently?

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Our primary target: Shame

11

What is shame?
From a behavioral standpoint:
Emotions refer to loose sets of covarying
behavioral repertoires that include such things
as attributions, physical arousal, facial and
bodily cues, behavioral predispositions, and
indicators of states of reinforceability
(establishing operations)

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Guilt vs Shame
In general, theorists argue that people
experience guilt when they have a negative
evaluation of their behavior or actions,
whereas shame involves a negative evaluation
of the self (Barrett, 1995; Tangney, Stuewig, &
Mashek, 2006).

13

Action Tendencies in Shame

Hide, withdraw, disappear
Blame others for event (shift blame from self)

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Nonverbal indicators of Shame

Hunched shoulders
Facial touching
Blushing
Gaze and head movements downward
Decreased levels of expressive behaviors
Avoidance of contact with others (e.g., eye
contact)
Appeasement behaviors
15

Match the emotion to the attribution

Shame, Guilt, or Anger
Blames other:

Anger

Blames ones own actions:

Blames ones self:

Guilt

Shame
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Shame vs. Guilt: A Brief Review

PTSD symptom severity (Leskela et al., 2002):
Shame was positively related; guilt was unrelated

Suicide (Lester, 1998; Hastings, Nortman, & Tangney, 2000):

Shame related to greater suicidal ideation, suicidal thoughts, but not
of attempts; guilt unrelated to suicidality

Substance abuse problems (Dearing, Stuewig, & Tangney, 2005 :

)

Shame related to greater; guilt related to fewer

Immunological function (Dickerson et al. 2004):

Shame related to poorer immunological correlated (i.e., cytokine
activity); guilt unrelated
17

Shame is a self-conscious emotion

Requires a sense of I in order to have

something to evaluate

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To understand shame, we need to

have a model of the self

19

Part 2
The ACT model of self

20

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From and ACT standpoint,

self is behavior
In an important sense, there is no self, rather
people are constantly selfing.
Self and I are words that have particular
functions.

21

The self is intrinsically social

There is a difference between behaving and
reporting that one is behaving.In arranging
conditions under which a person describes the
public of private world in which he lives, a
community generates that very special form
of behavior called knowing. B.F. Skinner
22

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How selfing is trained

The verbal community trains children to make
self-discriminations by asking questions and
reinforcing certain answers

23

A Conceptualized Self Emerges

Questions are asked about the person as an
object of verbal knowledge
These ways of speaking seem to be about the
qualities of the self, like an object has qualities

24

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Maggie,
howVery
old good!
are you?
Thats
right!

I am two.
25

Whats
your
name?
Yes,
you are
Maggie!

Maggie.
26

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No. What
You like
suck
doto
you
likeon
toyour
do?
pacifier.

Pizza.
27

A Conceptualized Self Emerges

As we grow, we are taught to provide
acceptable and coherent stories about
ourselves that justify and explain what we do
We are taught to detect and maintain
consistency between what we say and do

28

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The conceptualized self is

Well-elaborated
Touches on every verbally known aspect of life
(e.g. history, situation, preferences, abilities,
private events)

Multi-layered
Difference selves occur in different contexts

Rigid
Historical, and thus, seemingly unchangeable
Basis for reason-giving
29

Self as process
The verbal community also asks questions about
a persons ongoing behavior
People learn to describe what they did, what they
want to do, what they are feeling and thinking

30

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What are
you
feeling?
Im
glad.

I am happy.
31

What
doyou
youtoo.
see?
I see

I see you.
32

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I was
justdid
watching
What
you do,TV.
boy?

33

No you werent!!!!
I saw you steal that doughnut!

34

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The Knowing Self (self as process)

Ongoing, fluid description of present moment
experience
I feel, I think, I wonder, I like, I hear, I remember

Extremely useful in behavioral regulation

Allows others to predict behavior without knowledge of individual history
Self knowledge of ongoing experiences is useful

35

Self as process
The knowing self feeds the conceptualized self
In order to know that I am a depressed person,
I must first know that I frequently feel sad and
have low energy across many contexts

I am not me, me is what I create

36

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Three senses of self in ACT

An object of verbal knowledge
The conceptualized self
Self as content
A process of verbal knowledge
Self as process
A locus of verbal knowledge
Transcendent self
Observer self
Self as context or self as perspective

37

Self as context emerges with training on

perspective taking
Relation Frame Theory explains how this
occurs

38

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Relational Frame Theory

Stimulus Equivalence:
An Example of the Core Verbal Process
Limoo

Limoo

Betrang

Berl

Norna
39

If you test this, what happens?

Show

Pick?

Limoo

Berl

Norna

40

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The Derived Effects

Limoo

Betrang
Function (e.g.,
taste)

Derived Function
(e.g., taste)

41

Most relational frames are initially trained using

formal or non-arbitrary exemplars
This chair is bigger than that chair
Steve has less hair than Homer

<
42

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Perspective-Taking Frames
Some frames have no non-arbitrary
counterparts and must be taught through
demonstration and multiple exemplars
Such frames include DEICTIC frames or
perspective-taking frames
I-YOU
HERE-THERE
NOW-THEN

43

Perspective-Taking
A person is always speaking from the
perspective of I-HERE-NOW about events that
happen THERE and THEN
Words like I and YOU do not define
perspective-taking frames; they are Crels that
often control perspective-taking frames
Responding in accordance with deictic frames
allows us to evaluate, compare, contrast, and
judge events from a constant perspective
44

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A Single Relation Task

I have a white brick and you have a red brick
Which brick do you have?

Which brick do I have?

45

A Reversed Relation Task

I am sitting here on the blue chair and you are sitting
there on the black chair
Here:

There:

If HERE was THERE

and
THERE was HERE
Where would I be sitting?
Where would you be sitting?
46

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A Double Reversed Relation Task

Yesterday I was sitting there on the black chair, today I
am sitting here on the blue chair
There:
Here:
Now:

Then:

If HERE was THERE and THERE was HERE

and
NOW was THEN and THEN was NOW
Where would I be sitting now?
Where would you be sitting then?
47

You cant escape it

Once basic relational frames are established,
they occur everywhere, almost all the time
Even right now, you are constantly using
deictic frames.

48

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49

Who are you?

failure.
ashort.
therapist
I am amarried.
healthy.
old.

50

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5/5/2013

How do you feel?

I am ashort.
healthy.
out
married.
therapist
failure.
of time.
I feel worried.
sad.
elated.
confused.
calm.
angry.

51

What do you think?

I am ashort.
healthy.
out
married.
therapist
failure.
of time.
I feel worried.
sad.
elated.
confused.
calm.
angry.
I think Ill
about
life
he
Im
this
try
issucks.
lost.
iswrong.
good.
it.
love.

52

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5/5/2013

What do you want?

I am ashort.
healthy.
out
married.
therapist
failure.
of time.
I feel worried.
sad.
elated.
confused.
calm.
angry.
I think Ill
about
life
he
Im
this
try
issucks.
lost.
iswrong.
good.
it.
love.
I want to
a new
more
some
leave.
kill
see
money.
him.
pizza.
job.
her.

53

What do you see?

I am ashort.
healthy.
out
married.
therapist
failure.
of time.
I feel worried.
sad.
elated.
confused.
calm.
angry.
I think Ill
about
life
he
Im
this
try
issucks.
lost.
iswrong.
good.
it.
love.
I want to
a new
more
some
leave.
kill
see
money.
him.
pizza.
job.
her.
I see your
the
stars.
ahis
way
rainbow.
eyes.
car.
point.
out.
54

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5/5/2013

What did you do?

I am ashort.
healthy.
out
married.
therapist
failure.
of time.
I feel worried.
sad.
elated.
confused.
calm.
angry.
I think Ill
about
life
he
Im
this
try
issucks.
lost.
iswrong.
good.
it.
love.
I want to
a new
more
some
leave.
kill
see
money.
him.
pizza.
job.
her.
I see your
the
stars.
ahis
way
rainbow.
eyes.
car.
point.
out.
I did dirty
your
another
my
the
it
again
taxes.
yardwork.
laundry.
deeds.
(oops).
one.
55

Only one thing is consistent.

The context where

the answer occurs

I am ashort.
healthy.
out
married.
therapist
failure.
of time.
I feel worried.
sad.
elated.
confused.
calm.
angry.
I think Ill
about
life
he
Im
this
try
issucks.
lost.
iswrong.
good.
it.
love.
I want to
a new
more
some
leave.
kill
see
money.
him.
pizza.
job.
her.
I see your
the
stars.
ahis
way
rainbow.
eyes.
car.
point.
out.
I did another
myagain
the
it
not
your
taxes.
yardwork.
want
laundry.
(oops).
one.
that.

56

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5/5/2013

content

Self-as-context

want
see
more
some
to
the
stars.
ahis
your
new
way
rainbow.
leave.
kill
see
eyes.
car.
point.
money.
him.
pizza.
out.
job.
her.
I did
feel another
am
think
my
the
it
not
your
ashort.
sad.
elated.
confused.
calm.
angry.
worried.
healthy.
out
married.
about
life
he
Im
this
Ill
therapist
failure.
again
try
is
taxes.
sucks.
yardwork.
want
lost.
of
islaundry.
wrong.
good.
it.
time.
love.
(oops).
one.
that.

57

Observer self exercise

58

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Unfortunately
The same training in perspective taking that
allows the emergence of self as context and
transcendence (perhaps the basis of
spirituality) also allows for the development of
shame

59

Research on development shows that shame

develops later than other more basic emotions
(e.g., anger, sadness, surprise, disgust)
2nd yr: Children begin to develop perspectivetaking
3rd yr: Appearance of shame

60

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McHugh, Barnes-Holmes,
& Barnes-Holmes (2004)

Development of
Perspective Taking Shame
starts here
80
70
60
50

Errors

40
30
20
10
0

Adults

Adoles.

Late
C/hood
Age Range

Mid
Early
C/hood C/hood

Deictic relational framing (I-You, Here-There, Now-Then)

ability correlates with data from Theory of Mind studies
61

Shame disrupts perspective taking

Individuals describing a shame-inducing
situation are less likely to express empathy for
others in the situation (Tangney et al., 1994)
Experiences of shame related to difficulty in
taking anothers perspective on an event
(Leith & Baumeister, 1998)
In a shame-induction study, participants were
less likely to feel empathy for a disabled
student (Tangney & Dearing, 2002)
62

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What do we do about this?

63

Acceptance and
Commitment
Therapy

Contact with the

Present Moment

Values
Acceptance

Defusion

Committed Action

Perspective taking self

64

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Instead of suppressing,
avoiding, or trying to
change your emotions -- Acceptance

Contact with the

Present Moment

Values

Defusion

Committed Action

Perspective taking self

65

Contact with the

Present Moment

Values

Acceptance

Learning to observe
judgmental ,
categorical thought
Defusion

Committed Action

Perspective taking self

66

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Being Present slowing down

and showing up to the now

Values

Acceptance

Defusion

Committed Action

Perspective taking self

67

Contact with the

Present Moment

Acceptance

Defusion

Values

Committed Action

Flexible perspective taking being a conscious

and flexible observer of experience
68

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Contact with the

Present Moment

Acceptance

Values what do
you want to be
about?

Defusion

Committed Action

Perspective taking self

69

Contact with the

Present Moment

Values

Acceptance

Commitment and
how to do you get
your feet moving in
the direction of
what matters to
you?

Defusion

Perspective taking self

70

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Acceptance and
Mindfulness
Processes

You can chunk them

into two larger groups
Contact with the
Present Moment

Values
Acceptance

Defusion

Committed Action

Perspective taking self

71

Commitment and
Behavior Change

and
Contact with the
Present Moment

Processes

Values
Acceptance

Defusion

Thus the name

Acceptance and
Commitment
Therapy

Committed Action

Perspective taking self

72

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The Common Core of All of

These Processes is

Contact with the

Present Moment

Values
Acceptance

Psychological
Flexibility

Defusion

Committed Action

Perspective taking self

73

Psychological Flexibility

Two parts:
1) the ability to be
psychologically
present
2) the ability to control
your behavior to
serve valued ends

74

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Undermining
Avoidance

Contact with the

Present Moment

Values

Acceptance

Defusion

Committed Action

Perspective taking self

75

Undermining
Avoidance

Building
Contact with the
Present Moment

Approach

Values

Acceptance

Defusion

Committed Action

Perspective taking self

76

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Undermining
Avoidance

Building
Contact with the
Present Moment

Values

Acceptance

Open

Approach

Centered

Defusion

Engaged

Committed Action

Perspective
taking self

77

ACT as an intervention for Shame

Acceptance - Develop willingness to acknowledge and
embrace shame in and out of session
Defusion - Develop distance, distinction from selfattacking thoughts, observing self-critical thoughts
as thoughts.
Self as Context Develop contact with transcendent
sense of self and practice taking perspective of
others
Values Build a positive agenda of human connection
and understanding
Commitment - Help client take steps to act on values
while practicing gentleness and compassion

And do all this in the present moment, experientially

78

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Weight-related stigma
(Lillis, Hayes, Bunting,& Masuda, 2009)

84 people who completed at least six months of a

weight loss program
Randomized to six hour of ACT workshop focused
on self-stigma (n = 40) vs TAU Control (n = 44)
Used Get Out of Your Mind and Into Your Life to
reduce patterns of avoidance toward weight-related
thoughts, feelings, and bodily sensations, especially
shame / stigma; and increase values-based action
Nothing on diet and exercise

79

Control

Outcome Improvements

ACT
0.8
0.6
0.4
0.2
0
-0.2
Stigma

Distress

QOL

Improvement expressed in terms of Baseline SD 80

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3 Mo Follow-Up Weight Change

35
30

p < .001
ACT

15
10
5

3 month
follow-up
Control

25
20

d = 1.21

0
% gaining 5+ lbs

% losing 5+ lbs
81

Group ACT for Self-Stigma and Shame

Luoma et al. (published in JCCP, 2012)
Funded by NIDA R21 (PI: Kohlenberg)
134 participants in a 28 day inpatient drug program
Randomly assigned in waves to receive treatment as
usual or that plus a 6-hour ACT group focused
particularly on self-stigma and shame
Thus the total difference in the program is small
about 3-5% of the treatment hours
71% available in whole or in part at follow up (not
counting those the IRB prohibited contacting)
82

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The controversy
social psych

evolutionary psych

Shame is a
maladaptive
emotion that
should be reduced
quickly in order to
deal with its toxic
impact

All emotions have

evolved to have
adaptive functions,
including shame.

vs

83

Potential adaptive functions of shame

Intrapersonal function
shame serves as punishment following
transgressions or as anticipatory feedback when
considering potential deviations from societal
norms or personal values.

Effect of avoiding or suppressing shame

People can continue deviant behavior, such as
problematic drug use, or violate social norms or
personal values without feeling the shame that
would ordinarily accompany those actions
84

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Potential adaptive functions of shame

Interpersonal function
the expression of shame tends to evoke sympathy,
cooperation, and prosocial responding in others
(Keltner & Harker, 1998; Beer & Keltner, 2004) and
serves to repair strained social roles

Effect of avoiding or suppressing shame

Appropriate expression of shame could be part of
repairing disrupted relationships, increasing social
inclusion, and building social support. This is lost.
85

Notice your automatic emotional reaction as

I present the following images

86

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87

88

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89

90

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Our target
Help people learn to experience shame in a
more open and mindful fashion, so that
shame can perform its regulatory function of
warning against or punishing violations of
personal values or social norms and of helping
to repair strained social roles

91

Group ACT for Shame

Lets first look at the post outcomes but as
you do so reflect on the situations clinicians
face since these are the only outcomes that
would normally be seen directly by those
delivering treatment

92

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Shame Outcomes: Better for TAU

ACT

Average Score

110
105
100
95

TAU

90
85

Pre

Post
93

Quality of Life Outcomes: Better for TAU

Average Score

80
78
76
74

TAU

72

ACT

70
Pre

Post
94

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Social Support Outcomes: No Diff

Average Score

2.8

TAU
3.2

ACT
3.4
Pre

Post
95

Group ACT for Shame

Now lets look at what happens after they are
released from residential treatment

96

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Days / Month Using

Drugs or Alcohol

Group ACT for Shame:

Substance Use Outcomes
6
5

TAU

4
3
2
1

d = 1.21

ACT

0
1 Month

2 Month

3 Month

Follow Up

97

Shame Outcomes

Average Score

110

ACT

105
100
95
90

Change in shame
with use
at follow up
r = -.29, ns

Change in
Shame
Is this the
correlates with
weeks of usepink
at cloud?
3 Mo
follow up
= F-Up
TAU
-.37 (p < .01)

85
Pre

Post
98

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Quality of Life Outcomes

Average Score

80

ACT

78
76
74

TAU

72
70
Pre

Post

3 Mo F-Up
99

Social Support Outcomes

Average Score

2.8

ACT

TAU
3.2

3.4
Pre

Post

3 Mo F-Up
100

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Group ACT for Shame:

Treatment Engagement Outcomes

ACT

Tx attendance
follow-up

20
18
16
14
12

TAU

d = 1.48

10
8
101

Group ACT for Shame

Suggests that small interventions, focused on
the right processes, at the right time, can have
big effects.

102

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ACT for Shame

An open, self-compassionate, values based
approach may not be the quick way, but it is
likely a healthier way to make progress on
self-stigma and shame
Take people into the pain and the chatter
but give them the tools to do so in an
accepting, mindful way
103

What is compassion?
From an ACT perspective -- compassion and
self-compassion involve taking a mindful,
accepting, and loving stance with yourself and
your own thoughts and feelings, focusing on
what you value, and carrying those values
flexibly into your life and your involvement
with others

104

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Part 3
Lets practice

105

Acceptance Interventions
Develop willingness to acknowledge and embrace shame in and
out of session
People develop many ways to avoid shame--anger, shutting down,
addictive behavior, etc.
Examine workability of behaviors aimed at avoiding shame.
How do they avoid feeling bad about themselves or feeling
rejected? What happens in shame producing situations?
Bring process of shame and self-attacking into the room and
improve ability to sit with it and with reaction to self-attack
Practice willingness in relating shameful experiences to trustworthy
others (starting with therapist)
106

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Contact with the present

Do all of this experientially, in the moment
Teach client to notice evaluation/judgment as it
occurs in session
Help clients to notice avoidance of shame as it
occurs in session
Bring costs of self attack into the room:
Read aloud self-attacking thoughts, but imagine she
were saying them to a friend in the same position
Use a mirror when reading self-attacking thoughts to
self
Act out self-attack in chair work
107

Defusion
Develop distance, distinction from self-attacking thoughts.
Develop ability to observe self-critical thoughts as
thoughts.
Imagery imagine this critical self as if it were a person
(include tone, size, facial expression, etc.). Give it a name.
Naming the critizer develop a name for the critical side of
the self that has some endearing qualities

108

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Self as context
Develop connection a sense of self that
transcends our self concept

Distinguish self as context from self as content

Work on letting go of attachment to self as content, including self
evaluations
Practice perspective taking (loving kindness meditation, taking perspective
of shamers, taking perspective of therapist, and caring others)
Two chair exercises
Add a third chair, perhaps a compassion chair or observer chair for
experiencing the ongoing dialogue.
Have client be the compassionate therapist in the third chair. What
would that person say?

109

Values
Help person acknowledge and take a stand for their
values
People can avoid caring in order to avoid rejection,
shame, and self-criticism.
Can find values in shame, or in the reaction to selfattack, if client is able to stick with the attack or their
reaction to it.
Values provide context for acceptance and are what
makes acceptance different than wallowing or yet
another way to control pain.
Build connection with positive agenda of human
connection and empathy
110

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Committed action
Help client take steps to act on values while
practicing gentleness and compassion
Self-attacking can function as a way to coerce the self to
act in line with self-standards and values (e.g., buck up
and push through it). Committed action needs to be
tied to values, not self-coercion
Explore regrets and how past behavior has not aligned
with values - e.g., acting out funeral exercise
Increasing self-compassion can make it easier to take
risks, its like you have a friend who has your back.

111

Learning ACT
Core books

112

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Try some of these things

out with yourself

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Learn the basic

techniques

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Practice in the
therapist role

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Join ACBS (Association

for Contextual
Behavioral Science)
When you join ACBS, you will receive:
1) A comprehensive set of handouts for use with clients
2) Promotional materials to build your practice
3) A range of tools for assessment and case conceptualization
4) Scripts for a wide range of mindfulness and values exercises
5) Access to a vast archive of ACT papers and research articles
6) Free treatment protocols, videos, and audio recordings
7) Access to the ACT listserv, an active listserv where you can learn
about the new developments in ACT and interact with people from
all over the word.
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Learning ACT
Training opportunities
Come to the ACBS World Conference
in Sydney, Australia in July or in
Minneapolis, MN in 2014
Create/find a peer consultation group
(we have one in portland)
Watch DVDs, do online training or
phone consultation
Our emails: jbluoma@gmail.com,
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dr.lejeune@gmail.com

Get a little help from your

friends
You cant develop as an ACT
therapist alone
Either find or join or create your
own community around ACT

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Learning ACT
in Portland

Skills-focused training on working

with shame in clients, starting
fall 2013
Peer consultation group (every
second Friday 3:30-5:30)
If youre interested in either, fill out
sign-up sheet
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Please fill out the post

assessment before you leave.
Thank you.

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