Examining the Effectiveness of Self-Acceptance Group Therapy

Shame is an unpleasant self-conscious emotion that can be experienced following unwanted
outcomes and events (Lewis, 1971). Cognitively, shame involves the attribution of negative
outcomes to global, stable characterological flaws (e.g., thinking "That happened because I
am a bad person;" Tracy & Robins, 2006). Behaviorally, shame involves urges to avoid or
withdraw from other people in order to hide perceived flaws (e.g., Lindsay-Hartz et al.,
1995). Shame has been theoretically implicated in the development and maintenance of many
forms of psychopathology and problematic behaviors, including depression, social anxiety,
and borderline personality pathology (e.g., Beck & Alford, 2009; Clark & Wells, 1995; Rizvi
et al., 2011; Schoenleber & Berenbaum, 2012). Indeed, research indicates that shame is
ubiquitous in psychopathology (see Tangney & Dearing, 2002), resulting in increasing
recognition that treatments specifically addressing shame are needed (see Dearing & Tangney,
2011). Although a few promising and potentially shame-relevant treatments have recently been
described (Brown et al., 2011; Germer & Neff, 2013; Gilbert, 2011), no well-validated
treatments currently exist and these novel treatments generally do not address both the
cognitive and the behavioral components of shame.

Evidence that shame involves both problematic thinking patterns and maladaptive actions
suggests that effective interventions for shame need to address each of these components.
Indeed, there is some initial evidence that cognitive and behavioral therapy techniques can
reduce shame, at least in response to specific triggers. For example, cognitive
restructuring in the context of cognitive processing therapy has been found to reduce
trauma-related self-blaming thoughts (Resick et al., 2002), and women instructed in how to
use the dialectical behavior therapy opposite-action skill to address a specified shame
trigger reported reductions in shame about the given trigger (Rizvi & Linehan, 2005).

Drawing from this literature, a shame-focused intervention, Self-Acceptance Group Therapy
(SAGT), was developed to target both the cognitive and behavioral components of shame from a
cognitive-behavior therapy framework. SAGT is an 8-week group treatment that involves
psychoeducation and training in cognitive and behavioral shame-coping skills in order to
promote improvements in self-acceptance, which is the conceptual opposite of shame. For
example, group members are taught how to recognize and challenge shame-eliciting thoughts,
as well as how to effectively discuss shame-eliciting topics with others in order to
alleviate shame, foster adaptive social support, and enhance their ability to demonstrate
self-kindness/compassion. As in other cognitive-behavior therapies, group members complete
weekly homework assignments that allow them to practice their new skills. In addition,
in-session activities are used to promote further skills practice and target the social
disconnection created by shame. An initial version of SAGT was provided to 8 women Veterans
at the G.V. (Sonny) Montgomery VA Medical Center by one of the researchers (Dr.
Schoenleber). Preliminary data indicate that group members reported large reductions in
trait shame (d = 1.55) and improvements in self-acceptance (d = 2.15). Based on feedback
provided by these group members, an updated version of the SAGT protocol has been prepared.
The primary aim of the present study is to examine whether the current version of
Self-Acceptance Group Therapy is effective in improving shame, as well as emotional and
interpersonal functioning among individuals with elevated shame.

Based on theory and existing evidence, Hypothesis 1a is that individuals with elevated
initial levels of shame will report improvements on all outcome measures (e.g., trait shame,
self-acceptance, psychiatric symptoms) from pre-treatment to post-treatment, and Hypothesis
1b is that these gains will be maintained at follow-up one month after treatment completion.

Inclusion Criteria:

- Eligible participants will be adults (age 18 or older) who are fluent in English (as
all materials will be presented in English) and report elevated levels of trait shame
on the Experience of Shame Scale (ESS) at screening. Specifically, based on past
research, individuals must score at least 55 on the ESS screening items, which is
consistent with levels of shame often reported by clinical samples. In addition, all
interested individuals must have a therapist/case manager/psychiatrist who provides
them with individual psychotherapy on a regular basis and for whom the participant is
willing to sign an Authorization for Release of Health Information.

Exclusion Criteria:

- Individuals will be excluded from the present study if they do not report significant
difficulties with shame (i.e. ESS screening item scores less than 55), do not have an
individual therapist/case manager/psychiatrist who monitors and addresses their
broader mental health concerns, are experiencing active psychosis (i.e. delusions
and/or hallucinations), or are experiencing an episode of mania.