1. Self-compassion and shame-proneness in
five different mental disorders:
Comparison with healthy controls
J. BENDA, P. KADLEČÍK, D. KOŘÍNEK, M. DVOŘÁKOVÁ, A. VYHNÁNEK, T. ZÍTKOVÁ
ROOTS AND GIFTS OF INTEGRATIVE PSYCHOTHERAPY
PRAHA, 12.-14. 10. 2018
1

2. Background
2

3. 3
?
Anxiety
disorders
Depressive
disorders
Eating
disorders
Borderline
personality
disorder
Alcohol-
addiction
Transdiagnosticfactor

4. 4
shame
Anxiety
disorders
Depressive
disorders
Eating
disorders
Borderline
personality
disorder
Alcohol-
addiction
Transdiagnosticfactor

5. What is shame? 5
 Shame is a self-conscious emotion associated with
feelings of inadequacy, inferiority and
worthlessness and with a desire to hide or conceal
deficiencies.
 It is a “social” or “moral” emotion that can be seen as
resulting from the comparison of the self's action
and experiences with the self's standards.
 Shame-proneness is closely related to self-criticism.

6. Shame x guilt 6
 The fundamental difference between shame and guilt
concerns the role of the self.
 Shame involves fairly global negative evaluations of the self
(i.e., “I am not good enough, I am worthless”).
 Guilt involves a more articulated condemnation of a specific
behavior (i.e., „I did a bad thing”, see Tangney, Dearing, 2003).
 Shame is therefore a much more problematic – maladaptive
feeling (Cook, 2001; Greenberg, 2015).

7. Anxiety disorders
 Anxiety results from unconscious catastrophic
expectations
 What is the worst that could happen?
 (Fear of) condemnation, rejection,
abandonment
 = I am not enough, reprehensible (shame)
7

8. Depressive disorders
 Depressive rumination includes negative self-
narratives
 „I am impossible, unacceptable.“
 Hidden needs of acceptance, appreciation,
forgiveness or coping with loss are not
addressed
 Feelings of inferiority, humiliation, loneliness
(= shame)
8

9. Borderline personality disorder
 3 maladaptive shame regulation strategies
(Schoenleber, Berenbaum, 2012)
1. Prevention – e.g. the person avoids taking
responsibility for tasks
2. Escape – e.g. self-promotion or social withdrawal
3. Agression – e.g. the person refocuses self-hate onto
others and reacts accordingly
 All these strategies = Indirect indicators of shame
9

10. Eating disorders
 Body dissatisfaction, criticism of body image,
self-esteem closely linked to body
weight/shape
 The effort to attain body perfection connected
with hope for recognition, respect, admiration
 Never good-enough(= shame)
10

11. Alcohol addiction
 Alcohol provides immediate alleviation of
negative affect (e.g. shame)
1. I feel bad (trigger)
2. I drink some alcohol (behavior)
3. I feel good (reward) = reinforcement
 Substitution, true needs are not addressed
(see Brewer, 2017)
11

12. What is the best
protection
(or antidote)
against shame?
SELF-COMPASSION
12

13. What is self-compassion? 13
 According to Neff (2011b), self-compassion is a
cognitive coping strategy that reflects an emotionally
positive self-attitude in instances of perceived
inadequacy, failure, or general suffering.
 It is a counterpart of excessive self-criticism, self-
rejection, „hardness of heart“ or “self-coldness” (see
e.g. Boersma et al., 2015; Gilbert, 2010).

14. Self-compassion x self-pity 14
 Self-pity – the position of victim, egocentrism, blaming others,
self-rejection, the effort to control, manipulation, inability to
mentally leave a painful situation, inferiority (it's not fair, why
do bad things always happen to me?, everything is always my
fault, I'm the poorest man on earth)
 Self-compassion – accepting responsibility for oneself,
accepting own imperfections, caring for oneself, ability to ask
for help (to err is human, we are equal as humans, nobody is
less than anybody else)
(Paul, 2012; srov. Horniaková, 2015)

15. Self-compassion 15
 Self-compassion inspired the development of many new
psychotherapeutic procedures (see e.g. Desmond, 2016;
Germer, 2009; Gilbert, 2010; Neff, 2011a).
 Existing research confirms that:
1. self-compassion is most likely an important predictor of
mental health and well-being (Neff, 2011a,b; Trompetter,
2016; Zessin, Dickhäuser, Garbade, 2015) a
2. the lack of self-compassion probably plays an important role
in the etiopathogenesis of mental disorders (např. Hoge et
al., 2013; Krieger et al., 2013; MacBeth, Gumley, 2012, aj.).

16. THE ATTITUDE TO EXP. PHENOMENAAND MENTAL HEALTH
1. acceptance
2. rejection
(+ self-reference)
flow of
experiencing
experienced
phenomenon*
mental health
shame
defense
mechanisms
depressions addictionsanxieties eating disorders
psycho-
somatics
personality
disorders
and
more…
self-compassion (m. p. brahma vihára)
emotion dys/regulation
resistance (or self-coldness = tanhá)
* perception, feeling, image, thought, mood…
DOI: 10.13140/RG.2.1.5077.4167
16

17. Objectives 17
 The aim of this study was to compare the levels of self-
compassion and shame-proneness in samples of patients
with
1. anxiety disorders
2. depressive disorders
3. eating disorders
4. borderline personality disorder (BPD)
5. alcohol addiction
 and in healthy controls.

18. Methods
18

19. Anxiety sample (1) 19
 INCLUSION CRITERIA:
1. Primary diagnosis of phobic anxiety disorders or other anxiety disorders
(code F40-F41 according to ICD-10).
2. Age at least 18 years.
3. Rating of 10 or higher on the GAD-7 scale.
 Participants were excluded if they had a comorbid diagnosis of any
psychotic disorder, personality disorder, eating disorder, substance use
disorder, organic brain disorder or mental retardation.

20. Depressed sample (2) 20
 INCLUSION CRITERIA:
1. Primary diagnosis of major depressive disorder, single episode or major
depressive disorder, recurrent (code F32-F33 according to ICD-10).
2. Age at least 18 years.
3. Rating of 10 or higher on the PHQ-9 scale.
 Participants were excluded if they had a comorbid diagnosis of any
psychotic disorder, personality disorder, eating disorder, substance use
disorder, organic brain disorder or mental retardation.

21. BPD sample (3) 21
 INCLUSION CRITERIA:
1. Primary diagnosis of emotionally unstable personality disorder (code
F60.3 according to ICD-10).
2. Age at least 18 years.
 Participants were excluded if they had a comorbid diagnosis of any
psychotic disorder, eating disorder, substance use disorder, organic brain
disorder or mental retardation.

22. Eating disorders sample (4) 22
 INCLUSION CRITERIA:
1. Primary diagnosis of anorexia nervosa or bulimia nervosa (code F50.0 or
F50.2 according to ICD-10).
2. Age at least 18 years.
3. Rating of 15 or higher on the three eating-disorder-specific subscales of
the EDI scale.
4. Participants were excluded if they had a comorbid diagnosis of any
psychotic disorder, personality disorder, substance use disorder, organic
brain disorder or mental retardation.

23. Alcohol addiction sample (5) 23
 INCLUSION CRITERIA:
1. Primary diagnosis of alcohol dependence (code F10.2 according to ICD-
10).
2. Age at least 18 years.
3. Rating of 20 or higher on the AUDIT scale.
 Participants were excluded if they had a comorbid diagnosis of any
psychotic disorder, eating disorder, organic brain disorder or mental
retardation.

24. Healthy controls (0) 24
 INCLUSION CRITERIA:
1. Age at least 18 years.
2. Rating ≤ 9 on the GAD-7 scale.
3. Rating ≤ 9 on the PHQ-9 scale.
 Participants were excluded from this sample if they reported a history of
any mental disorder or if they had a score ≥ 10 on the GAD-7 scale or the
PHQ-9 scale.

25. Measures
 Self-Compassion Scale (SCS-26-CZ, Neff, 2003; Czech version
Benda, Reichová, 2016). Recently, critique has been raised
regarding the factor structure of the SCS and the validity of
the SCS total score (Benda, 2018; Muris, Otgaar, Pfattheicher,
2018). Therefore, only the Compassionate Self-responding
subscale (13 items) was used in this study.
 Test of Self-Conscious Affect-3S (TOSCA-3S, Tangney,
Dearing, 2003; Czech version Dvořáková, 2013). Only the
shame-proneness subscale was used in this study.
25

26. Measures
 Generalized Anxiety Disorder-7 (GAD-7; Kroenke et al.,
2010).
 Patient Health Questionnaire-9 (PHQ-9; Kroenke et al.,
2010).
 Eating Disorder Inventory (EDI; Garner, Olmstead, & Polivy,
1983). Only the eating-disorder-specific subscales (i.e. Drive
for Thinness, Bulimia, Body Dissatisfaction) were used in this
study.
 The Alcohol Use Disorders Identification Test (AUDIT;
Babor et al., 2001).
26

27. Statistical analysis
 Data was analyzed using the IBM SPSS Statistics software,
Version 23.
 Associations between study variables were analysed by
calculating the Pearson’s correlation coefficients.
 Differences in self-compassion and shame-proneness were
analyzed using a two-way analysis of covariance (ANCOVA)
with Bonferroni correction.
 The effect sizes of the group comparisons were then
calculated in terms of Cohen’s d.
27

28. Results
28

29. Demographic characteristics 29
N age (SD) males females
anxiety sample 58 41.26 (13.02) 18 40 (69%)
depressed sample 57 43.46 (13.68) 19 38 (66.7%)
BPD sample 74 31.55 (8.58) 20 54 (73%)
eating disorders sample 55 26.18 (9.10) 0 55 (100%)
alcohol addiction sample 55 43.25 (11.64) 34 21 (38,2%)
healthy controls 180 40.55 (8.43) 62 118 (65.6%)

30. Correlations between compassionate self-
responding and shame-proneness
anxiety sample -.38**
depressed sample -.25**
BPD sample -.46**
eating disorders sample -.33*
alcohol addiction sample -.01
healthy controls -.27**
*p<0,05
**p<0,01
30

31. Boxplot of
compassionate
self-responding
scores by group.
31

32. Boxplot of
shame-
proneness
scores by
group
32

33. Comparison of samples
 The samples differed significantly in age (F(5, 473) = 29.747, p
< .001) and gender (χ2(5, N = 479) = 90.201, p < .001).
 To determine if there were significant group differences in
study variables, two two-way ANCOVAs were conducted with
the group and gender as fixed factors, age as a covariate and
compassionate self-responding and shame-proneness as
dependent variables. For pairwise comparisons post hoc t-
tests with Bonferroni correction were then performed.
33

34. Means and standard deviations of
study variables
anxiety
sample
depressed
sample
BPD
sample
eating
disorders
alcohol
addiction
healthy
controls
F p η2
SCS-26-CZ-CS
33.78
(7.98)
34.58
(6.42)
28.00
(8.77)
28.36
(7.76)
34.22
(8.24)
43.11
(8.19)
40.659 < .001 .303
TOSCA-3S-S
36.52
(8.90)
34.25
(7.04)
39.32
(9.06)
39.85
(7.26)
32.95
(7.35)
28.26
(8.02)
28.749 < .001 .235
34
Post-hoc t-tests with Bonferroni correction indicated that all five
clinical samples showed significantly lower compassionate self-
responding and significantly higher shame-proneness than healthy
controls (all p’s < .001).

35. Effect-sizes (d) for comparisons between
clinical groups & healthy controls
35
SCS-26-CZ-CS TOSCA-3S-S
anxiety sample vs. healthy controls 1.15 .98
depressed sample vs. healthy controls 1.16 .79
BPD sample vs. healthy controls 1.78 1.29
eating disorders sample vs. healthy controls 1.85 1.52
alcohol addiction sample vs. healthy controls 1.08 0.61

36. Conclusion
36

37. In the present study
1. All five clinical samples were found to have
significantly lower self-compassion and significantly
higher shame-proneness than healthy controls. Both
the lack of self-compassion and shame-proneness
thus proved to be transdiagnostic factors of these
disorders.
2. The lack of self-compassion was essentially
associated with shame in almost all samples (except
alcohol addiction sample).
37

38. We hypothesize, that
1. the lack of self-compassion leads to the formation of shame
whenever one experiences something that is perceived to be
“wrong” in comparison with one’s self-ideal. And since shame is a
painful feeling, various defense or coping mechanisms are then
automatically activated, resulting in various psychopathological
symptoms. Further study of these mechanisms may lead to a new
understanding of the etiology of many mental disorders as well
as a new understanding of the mechanisms of therapeutic
change in these disorders.
2. clients suffering from all investigated disorders may benefit from
treatments or particular interventions that facilitate the
development of self-compassion or shame management.
38

39. Inspiration
39

40. Inspiration 40
 With regard to the critique of the Self-Compassion
Scale (see e.g. Muris, Otgaar, Pfattheicher, 2018) we
recommend to replicate this study with another
measure of self-compassion, such as the Sussex-
Oxford Compassion for the Self Scale (SOCS-S;
Strauss, Gu, 2018). As a measure of shame we
recommend to use the Internalized Shame Scale
(ISS; Cook, 2001; Benda, Kadlečík, Dvořáková, in
press).

41. Inspiration 41
 It would be desirable to closely compare findings of
transdiagnostic research, research on self-compassion
and research on shame. We believe, that these so far
rather independent research streams have much to offer
each other.
 The same can probably be said for therapies focused on
the treatment of shame and on the development of
compassion or self-compassion (Boersma et al., 2015;
Desmond, 2016; Germer, 2009; Gilbert, 2010; Jazaieri et
al., 2014; Neff, 2011a; Reddy et al., 2013; Schoenleber,
Gratz, 2018).

42. Inspiration 42
Another interesting
comparison could then
be made between
existing knowledge of
self-compassion, shame
and some relevant new
findings of neuroscience
research (see e.g. Stevens,
Woodruff, 2018; Porges,
2011, 2017).

43. Acknowledgements
 This research was partly supported by the Grant Agency of the Charles
University under research Grant No. 44317.
 We would like to thank the medical staff of
 Psychiatric Hospitals in Červený Dvůr, Kosmonosy, Kroměříž, Havlíčkův Brod, Prague-
Bohnice, and Opava,
 Anabell Center in Prague, Kaleidoskop - Center for therapy and education in Prague,
the Psychotherapeutic and Psychosomatic Clinic ESET in Prague, Fokus Praha, Hélio
- Center for Mental Health in Prague
 Departments of Psychiatry at the General University Hospital in Prague, the Military
University Hospital Prague, the Institute for Clinical and Experimental Medicine in
Prague, the University Hospital Olomouc, the Military Hospital Olomouc and the
Regional Hospital Jičín
 for their kind cooperation.
 Special thanks to prim. MUDr. Jiří Dvořáček and prim. MUDr. Adéla
Stoklasová.
43

44. Thank you for
your attention!
44
This presentation can be downloaded
from:
www.jan-benda.com
Contact:
psychoterapeut@gmail.com

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51. How to cite this presentation:
 Benda, J., Kadlečík, P., Kořínek, D., Dvořáková, M., Vyhnánek, A., & Zítková,
T. (2018). Self-compassion and shame-proneness in five different mental
disorders: Comparison with healthy controls (Presentation). Roots and Gifts
of Integrative Psychotherapy - The 9th Conference of the European
Association of Integrative Psychotherapy. Prague, 12.-14. 10. Retrieved
from https://www.slideshare.net/janbenda1
51