Treatment Approaches to Reduce Shame: A Systematic Review

Background: Shame is a deeply painful emotion that leads to a variety of negative health outcomes including depression, anxiety, stress, suicidality, substance use, and eating disorders, giving rise to feelings of disconnection and loneliness. While there is a wealth of clinical and research literature on the occurrence and deleterious impact of shame, to date there has been no synthesis of shame measures or therapeutic interventions to reduce shame. As such, the purpose of this systematic review was to examine studies on interventions to reduce shame, including a review of standardized instruments to assess shame.

Methods: The systematic review followed Prisma guidelines and was registered with Prospero. Three electronic databases, PubMed, PsycINFO, and CINAHL, were used to search for articles. Included studies met the following criteria: published in peer-reviewed journal in English, used a standardized instrument to assess shame, and used quantitative methods to evaluate the impact of an intervention to reduce shame. Searches yielded 1,304 unique articles for title and abstract review. The title and abstract review reduced the number of articles to 53. Finally, full-text review resulted in 32 studies that fully met inclusion criteria. Following full text review, risk of bias tools from the National Heart, Lung, and Blood Institute were used to assess study quality. Two coders independently reviewed each study utilizing a third independent coder when necessary to reach consensus. Finally, data on study design, intervention, sample characteristics, shame measure, the context in which shame was being treated (e.g., trauma, body image), and effectiveness of interventions to reduce shame were extracted and synthesized.

Results: A total of 4,836 individuals participated across 32 included studies, of which 14 used a randomized control trial design, 17 used pre/post-test, and one used case-control design. Seventeen different standardized measures of shame were used, six of which were shame-related subscales of validated instruments. Seven of the measures were used in more than one study. The context of shame varied widely including trauma, health conditions, body image and sexual health. The most common types of interventions were Cognitive Behavioral and Mindfulness followed by psychoeducation and psychodynamic approaches. All but one of the 32 studies reported reductions in shame at post-test. All six studies that included follow-up assessment reported sustained reductions in shame at two to six months.

Implications: Shame occurs in a variety of psychosocial contexts, especially those that carry social stigma, and appears to be highly malleable: 97% of studies in this review showed significant reductions. A range of commonly used interventions were represented in the studies, suggesting that practitioners likely already possess tools to help clients reduce shame. Future research and treatment dismantling studies are needed to identify active ingredients of interventions that effectively reduce shame with various populations and contexts. Despite the connection between stigma and shame, surprisingly, none of the studies addressed internalized shame among stigmatized social identities (e.g., sexual minorities). Due to shame’s negative impact on well-being, it’s important for social work practitioners to be aware of its pervasiveness but also its malleability and responsiveness to treatment.