Shame

Shame is a powerful self-conscious emotion characterized by feelings of being fundamentally flawed, unworthy, or defective as a person. Unlike guilt, which focuses on specific actions, shame targets one's core identity and self-worth. Understanding and addressing shame is crucial for mental health, as research shows it plays a significant role in various psychological conditions and can profoundly impact quality of life.

Recent studies demonstrate that shame is strongly associated with the severity of psychotic symptoms in clinical and non-clinical populations, and a meta-analysis revealed a significant moderate association between shame and posttraumatic stress symptoms, r = .49, 95% CI [0.43, 0.55], p < .001. With 23.4% of U.S. adults experiencing mental illness in 2024 (61.5 million people), addressing shame as a contributing factor has become increasingly important in mental health treatment.

Table of Contents

• What Is Shame?
• The Difference Between Shame, Guilt, and Embarrassment
• How Shame Develops
• The Impact of Shame on Mental Health
• Shame and Specific Mental Health Conditions
• Treatment Approaches for Shame
• How Therapy Can Help
• Frequently Asked Questions
• Find a Therapist

What Is Shame?

Shame is a self-conscious emotion involving the painful feeling that one is inherently bad, inadequate, or unworthy. Shame experience and regulation are of crucial importance in the study of emotion and psychopathology. Considering the variety of conceptualizations and operationalization methods in the shame literature, researchers have identified key characteristics that distinguish shame from other emotions.

Shame is a self-conscious feeling that is closely related to both internal self-judgment and social evaluation. When experiencing shame, individuals often feel:

• A sense of being fundamentally flawed or defective
• An urge to hide, disappear, or withdraw from others
• Physical sensations such as blushing, avoiding eye contact, or a collapsed posture
• Cognitive distortions about their worth as a person

Research using neuroimaging has revealed that both guilt and shame/embarrassment were associated with the activation of the left anterior insula, involved in emotional awareness processing and arousal. Guilt-specific areas were located within the left temporo-parietal junction, which is thought to be involved in social cognitive processes.

The Difference Between Shame, Guilt, and Embarrassment

Understanding the distinctions between these self-conscious emotions is essential for proper assessment and treatment:

Shame vs. Guilt

Unlike guilt, shame is a uniquely destructive emotion that exists without any real purpose. Whereas guilt involves reflecting on a detrimental action or behavior, shame is an internal, self-conscious emotion that makes a person feel profoundly flawed and worthless. Key differences include:

• Focus: Guilt focuses on actions ("I did something bad"), while shame focuses on the self ("I am bad")
• Function: While shame and guilt are equally unwelcome emotions, guilt can encourage someone to make amends and improve self-perception. Shame, on the other hand, offers no such path and serves only to punish oneself
• Behavioral response: Guilt motivates reparative action, while shame leads to withdrawal and avoidance

Shame vs. Embarrassment

Shame exhibits notable cultural variability. Giorgetta et al. (2023) discovered that Italians distinguish shame from guilt more clearly than Americans, suggesting that cultural schemas have a significant impact on emotion. Embarrassment typically:

• Is more fleeting and situation-specific
• Involves concern about social evaluation in the moment
• Resolves more quickly once the situation passes
• Is less likely to impact core self-worth

How Shame Develops

Early Life Experiences

That being said, when we are little ones, growing up in dysfunction, healthy shame can turn toxic. It becomes the go-to mechanism and we will turn it inward, resulting in a loud, harsh, and unrelenting inner critic who has lots to say and none of it is nurturing. When healthy shame turns toxic, its purpose is to keep us small and silent to try to mitigate the risk of repeated chronic, consistent trauma and abuse.

Shame often develops through:

• Childhood trauma and abuse: It is understandable to experience feelings of helplessness and shame in complex PTSD. When there is no way to stop abuse, end a situation of domestic violence, or convince a parent to stop drinking, a child feels powerless
• Critical or shaming parenting: When a child growing up in a dysfunctional environment makes a mistake, the caregiver may say, "You are so clumsy, stupid, how could you do that?" This moment is the break in attunement. Toxic shame has now been established
• Cultural and religious conditioning: Many cultures and religions use shame to enforce behavioral norms
• Peer rejection or bullying: Social exclusion during formative years can create lasting shame

Neurobiological Factors

Shame has a distinct facial thermal profile compared to guilt and remorse (Bhushan et al., 2020b), and it has been demonstrated physiologically to impair endothelial function, affecting cardiovascular reactivity (McGarity-Shipley et al., 2022). More than guilt, shame impairs executive functioning, particularly working memory (Cavalera et al., 2018).

The Impact of Shame on Mental Health

Depression and Anxiety

A significant increase was seen in the percentage of adults with anxiety symptoms (from 15.6% to 18.2%, respectively) and depression symptoms (from 18.5% to 21.4%, respectively) between 2019 and 2022. Increases in symptoms of anxiety and depression were seen throughout the subgroups examined.

Most recent 2023 data show 40% or 2 in 5 U.S. high school students reported experiencing symptoms of depression—felt so sad or hopeless every day for two or more weeks in a row that they stopped doing some usual activities in the past 12 months. The percentage was lower in 2023 than it was in 2021.

PTSD and Trauma

Certain types of trauma are notorious for producing feelings of shame in their victims, particularly sexual violence, childhood abuse, and intimate partner violence, all of which are strongly associated with the development of PTSD due to their extremely dehumanizing and humiliating nature. While PTSD is officially classified as an anxiety disorder that manifests primarily in pathological fear, the International Society for Stress Studies (ISTSS) notes: [T]his fails to capture an essential characteristic of those traumas that are of human design, especially those that are repeated over an extended period of time. In these cases, where a relationship of dominance and subordination is established, feelings of humiliation, degradation, and shame are central to the victim's experience. The result can be viewed as both an anxiety disorder and a shame disorder.

Social Anxiety Disorder

Social anxiety disorder (SAD) is one of the most prevalent psychological disorders and generally co-occurs with elevated shame levels. Previous shame-specific interventions could significantly improve outcomes in social anxiety treatments. Recent review suggests that integrating a more direct shame intervention could potentially increase the effectiveness of cognitive behavioral therapy.

Substance Use Disorders

16.8 percent of the U.S. population aged 12 or older (about 48.4 million individuals) met the criteria for a substance use disorder (SUD). This is similar to the 2023 report when 17.1 percent of the population (around 48.5 million people) reported a SUD.

First, through a process termed cognitive fusion, attachment to the literal meaning of self-critical and self-devaluing thoughts increases the likelihood of destructive behaviors such as substance use. Second, through a process termed experiential avoidance—the tendency to avoid difficult private experiences as a method of behavioral regulation even when it leads to problems—substances are used to avoid and suppress shame and other negative emotions. This reduces access to the potentially useful functions of shame, such as signaling a violation of social roles and personal values.

Shame and Specific Mental Health Conditions

Body Dysmorphic Disorder

Body Dysmorphic Disorder (BDD) is a severe mental health condition characterized by an obsessive focus on perceived flaws in one's appearance, often leading to significant distress and impairment in daily functioning. While Cognitive Behavioral Therapy (CBT) has been the gold standard treatment for BDD, many individuals do not respond adequately to this approach. Recent research suggests that shame plays a critical role in the development and maintenance of BDD symptoms. Therefore, targeting shame directly may enhance treatment outcomes for those suffering from this debilitating disorder.

Eating Disorders

Research has shown strong connections between shame and eating disorders. Matos, M, Coimbra, M, Ferreira, C. When body dysmorphia symptomatology meets disordered eating: the role of shame and self-criticism. Appetite 2023; 186: 106552, highlighting how shame-based self-criticism drives disordered eating behaviors.

Narcissistic Personality Disorder

Furthermore, internalized shame, which refers to a persistent feeling of worthlessness, inadequacy, and rejection, is another key feature in narcissistic personality disorder, often hidden beneath defensive grandiosity.

Treatment Approaches for Shame

Cognitive Behavioral Therapy (CBT)

The shame WCBT group showed a significant reduction in both shame and social anxiety after treatment compared to the normal WCBT and waiting groups. Problem-solving and self-blame mediated the effect of shame on social anxiety. In conclusion, this study supports previous findings that a direct shame-specific intervention component could enhance the efficacy of WCBT.

CBT approaches for shame typically include:

• Identifying and challenging shame-based thoughts
• Behavioral experiments to test shame beliefs
• Developing self-compassion practices
• Building adaptive coping strategies

Acceptance and Commitment Therapy (ACT)

In an ACT approach, rather than trying to reduce or eliminate shame, psychological acceptance techniques encourage participants to notice and experience shame and other difficult feelings more fully, while reducing their conditioned link to overt action. Negative self-judgments such as "I'm a loser" or "I am evil" are addressed by cognitive defusion: noticing the process of thinking, letting go of attachment.

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. ACT has been shown to effectively improve lifestyle in colorectal cancer survivors, glucose control and self-management behaviors in individuals who have diabetes, and diet and physical activity in patients with cardiac issues. Additionally, ACT has shown promising results in supporting overall quality of life and treatment adherence.

Compassion-Focused Therapy (CFT)

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.

Self-Acceptance Group Therapy (SAGT)

Self-Acceptance Group Therapy (SAGT) was developed as a transdiagnostic shame-focused treatment, based on a cognitive-behavioral framework. SAGT is an 8-week treatment that involves psychoeducation and training in the use of cognitive and behavioral shame regulation and support-building skills in order to promote self-acceptance.

How Therapy Can Help

Therapy provides a safe, non-judgmental space to explore and heal from shame. In closing, I want to remind you that healing shame in complex PTSD most often requires working with a compassionate therapist; one who can help you navigate the pitfalls and help you find freedom from shame.

Benefits of therapy for shame include:

• Building shame resilience: Building shame competence requires systemic change – creating environments that acknowledge shame with empathy, accountability and repair. Embedding this into healthcare leadership and culture promotes psychological safety and effective care
• Developing self-compassion: 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. It is associated with resilience, better stress regulation, health-promoting behaviors, and intrinsic motivation
• Processing trauma: Addressing underlying traumatic experiences that contribute to shame
• Improving relationships: Shame often interferes with connection; therapy helps rebuild trust and intimacy

Finding the Right Therapist

When seeking therapy for shame, look for professionals who:

• Have experience with trauma-informed care
• Use evidence-based approaches like CBT, ACT, or CFT
• Create a warm, accepting therapeutic environment
• Understand the cultural context of shame
• Can help you distinguish between healthy and toxic shame

Frequently Asked Questions

What's the difference between healthy shame and toxic shame?

Healthy shame serves as a social signal that helps us recognize when we've violated social norms or our own values. It's temporary and proportionate to the situation. Shame keeps us small and silent, to mitigate risk and keep us out of trouble where we could get hurt. That sounds like a pretty great mechanism inside our bodies and minds, doesn't it? Like a safety valve that gets flipped to try to keep us alive. However, when healthy shame turns toxic, its purpose is to keep us small and silent to try to mitigate the risk of repeated chronic, consistent trauma and abuse. As we grow up, this toxic shame doesn't just go away. It is the guiding principle in all our parts and has to be addressed for healing to happen.

Can shame be completely eliminated?

Rather than eliminating shame entirely, treatment focuses on developing a healthier relationship with this emotion. Though well-intentioned, these repeated attempts to reduce or avoid shame can exacerbate the sense of being defective, other, or unworthy already associated with shame and prevent people from living out their values in relationship with themselves and important others. Acceptance and Commitment Therapy (ACT) is a transdiagnostic treatment approach that aims to promote psychological and behavioral flexibility in response to painful internal experiences.

How does cultural background affect shame?

It exhibits notable cultural variability. Giorgetta et al. (2023) discovered that Italians distinguish shame from guilt more clearly than Americans, suggesting that cultural schemas have a significant impact on emotion. Cultural factors influence:

• What behaviors trigger shame
• How shame is expressed
• Whether shame is viewed as motivating or destructive
• Family and community responses to shame

Is online therapy effective for treating shame?

Yes, research shows that online therapy can be effective. Results: Participants' social anxiety symptoms and shame proneness in both the self-help and guided ICBT groups reduced significantly after treatment, with no significant differences between the two intervention groups. This suggests that both guided and self-help online therapy formats can successfully address shame.

How long does it take to heal from shame?

The timeline varies depending on several factors, including the severity of shame, its origins, and the treatment approach used. Web-based cognitive behavioral therapy (WCBT) has proven efficacy, sustaining benefits for 6 months to 4 years. Most structured treatments range from 8-12 weeks, though some individuals may benefit from longer-term therapy.

Can medication help with shame?

While there are no medications specifically for shame, treating co-occurring conditions like depression or anxiety can indirectly help. 66% of women in prison reported having a history of mental illness, almost twice the percentage of men in prison, highlighting how shame often co-occurs with other mental health conditions that may benefit from medication.

Find a Therapist

If shame is impacting your life, professional help is available. Most recent 2024 data show 14% or 1 in 7 U.S. adults received counseling or therapy from a mental health professional in the last 12 months. The percentage was higher in 2024 than it was in 2023.

GoodTherapy's directory can help you find a qualified mental health professional who specializes in treating shame and related conditions. Look for therapists who offer:

• Trauma-informed care
• Evidence-based treatments (CBT, ACT, CFT)
• Cultural competence
• A warm, non-judgmental approach

Remember, seeking help is a sign of strength, not weakness. With proper support, it's possible to develop a healthier relationship with yourself and reduce the impact of shame on your life.

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