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Effectively Treating Pathological Self-Criticism in Depressed & Dysthymic Clients
Effectively Treating Pathological Self-Criticism in Depressed and Dysthymic Clients

Section 17
Potential Foundations for Self-Criticism in Individuals

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The Problems of Shame and Self-Criticism
Stuewig and McCloskey (2005) explored various self-conscious emotions during children’s transition to adolescence and found that, over an eight year period, shame was mediated by parental humiliation and rejection. Feiring, Taska, and Lewis (2002) found that in both children and adolescents the ability to adjust to sexual abuse was significantly related to attributional style and the person’s experience of shame. Cheung, Gilbert, and Irons (2004) found that feelings of shame and inferiority can be a focus for rumination and are associated with depressive rumination. Shame therefore seems to have a certain ‘stickiness’ about it, which can easily pull individuals into a ruminative self-critical style, increasing vulnerability to a range of difficulties. Self-criticism is significantly associated with shame-proneness (Gilbert & Miles, 2000) and both are trans-diagnostic, permeate many disorders, increase vulnerability, effect expression of symptoms and elevate risk of relapse (Gilbert & Irons, 2005; Tangney & Dearing, 2002; Zuroff, Santor, & Mongrain, 2005). Zuroff, Koestner, and Powers (1994) found that self-criticism in childhood is a predictor of later adjustment.

Self-criticism is associated with lifetime risk of depression (Murphy et al., 2002). Some forms of shame-proneness are linked to early abuse and underpin forms of self-criticism (Andrews, 1998). Heimpel, Wood, Marshall, and Brown (2002) found that, following a setback, low self-esteem people appeared less motivated to improve their moods than high self-esteem people. They suggest two key processes may be involved. First, low self-esteem people experience a greater loss of energy to a mood lowering setback than high self-esteem people. Second, low self-esteem people struggle with far more self-criticism than high self-esteem people, setting up a vicious circle of a dip in mood triggering self-criticism that triggers a further dip in mood. Whelton and Greenberg (2005) have shown that the pathological aspects of self-criticism are not just related to the content of thoughts but to the effects of self-directed anger and contempt in the criticism.

High self-critics can find it hard to feel reassured by cognitive tasks and behavioural experiments (Lee, 2005) and dips in mood can trigger self-criticism in recovered depressed people (Teasdale & Cox, 2001). Rector, Bagby, Segal, Joffe and Levitt (2000) suggest that highly self-critical people may do less well with standard CBT, although the degree to which self-critical thinking can be modified is important to outcome. Psychodynamic therapists also recognize that self-criticism and self-persecution can be hard to treat (Scharffee & Tsignouis, 2003). Given the prevalence of shame and self-criticism, therapies that specifically focus on this element may be especially useful for some patients. Compassionate mind training (CMT) evolved from working with high shame and self-critical people (Gilbert, 1992, 1997, 2000; Gilbert & Irons, 2005).

The Importance of a Lack of Warmth, Soothing and Affection in Self-Criticism
The pathogenic qualities of shame and self-criticism have been linked to two key processes. The first quality is the degree of self-directed hostility, contempt and self-loathing that permeates self-criticism (Gilbert, 2000; Whelton & Greenberg, 2005; Zuroff et al., 2005). Second is the relative inability to generate feelings of self-directed warmth, soothing, reassurance and self-liking (Gilbert, 2000; Gilbert, Clarke, Kempel, Miles, & Irons, 2004; Linehan, 1993; Neff, 2003a; Whelton & Greenberg, 2005). Although reducing self-directed hostility is important to help high shame self-critics, CMT has also focused on developing abilities to generate feelings of selfreassurance, warmth and self-soothing that can act as an antidote to the sense of threat. The potential importance of developing inner warmth came from observations that some high self-critics could understand the logic of CBT and generate alternative thoughts to self-criticism but rarely felt reassured by such efforts (Lee, 2005). As noted above, such individuals often come from neglectful or traumatic backgrounds and have rarely felt safe or reassured. Indeed, we have found that feelings of warmth or gentle reassurance were often frightening for them. It seemed therefore as if these individuals could not access soothing-affect systems in their self-to-self processing (Gilbert, 2000). This raised two questions: (1) how might early backgrounds influence the balance between self-criticism and self-soothing? and (2) could we teach some high self-critics to stimulate a particular type of affect system that underpins soothing? To understand the value of such efforts requires a short detour into consideration of how ‘warmth and soothing systems’ have evolved as salient affect regulation systems, and why some self-critics may struggle with accessing these processing systems (Brewin, 2006).

The Human Warmth System
It is now generally agreed that one of the key evolutionary changes that emerged with the mammals was attachment and care provision for infants (Bell, 2001; Bowlby, 1969; Mikulincer & Shaver, 2004). In fact, many mammals (and especially humans) need, and are responsive to, signals of care and affection and have evolved attachment mechanisms that are sensitive and responsive to such signals (although some theorists distinguish warmth/affection from attachment/security/protection (MacDonald, 1992)). Not only do these signals of care/warmth create experiences of safeness (Gilbert, 1989, 2005a), they may do so by impacting on a specific kind of affect and affect regulation system. Recent research has indicated that there are two different, but interactive, positive affect (PA) systems. One PA system is focused on doing/achieving and anticipating rewards/successes. This system may be dopaminergic and is arousing and activating (Panksepp, 1998). The second system, however, is particularly linked to social signals of affiliation and care and involves neurohormones such as oxytocin and opiates (Carter, 1998; Depue & Morrone-Strupinsky, 2005; Panksepp, 1998; Uväns-Morberg, 1998). Signals and stimuli such as stroking, holding, voice tone, facial expressions and social support are natural stimuli that activate this system (Uväns-Morberg, 1998; Wang, 2005).

Activation and maturation of this system are especially important in the first years of life, where a parent acts as a reassuring and soothing agent (Gerhardt, 2004). In doing so the caregiver creates experiences and emotional memories of safeness, and enables infants (and later children) to understand and feel safe with their own emotions (Leahy, 2005; Schore, 1994). Such emotional memories, with their neurophysiological mediators, may then become available in times of stress (Brewin, 2006). It is now believed that parental neglect and abuse may fail to help this system mature, and indeed abuse and neglect can cause problems in brain maturation (Gerhardt, 2004; Schore, 2001). The threat systems for these children may be over-stimulated (Perry et al., 1995), making them more sensitive to threat and less emotionally regulated—in part because they may not have soothing experiences/memories that form the foundation for self-soothing. While soothing and affiliation lowers stress and cortisol, shame, negative evaluation and criticism by others is now known to be one of the most powerful elicitors of cortisol stress responses (Dickerson & Kemeny, 2004). The key aspect is thus that there appears to be a specific affect processing system that may underpin soothing/safeness that matures in the contexts of affectionate care. How might low activation of this system, together with high threat, influence self-criticism?

Insecure Attachment and Self-Criticism
Secure attachments give rise to internal working models of others as safe, helpful and supportive and these provide a source for self-evaluation and self-soothing (Baldwin, 2005; Mikulincer & Shaver, 2004, 2005). Insecure children, however, become more focused on others as sources of threat. In that context they become highly social rank focused, especially on the power of others to control, hurt or reject them (Gilbert, 2005a; Irons & Gilbert, 2005; Sloman, Gilbert, & Hasey, 2003). A series of studies by Dunkley and colleagues (e.g., Dunkley, Zuroff, & Blankstein, 2006) have explored various measures of perfectionism and suggest two underlying factors: the first is setting and striving for personal standards; the other is striving to avoid criticism/rejection from others and was labeled ‘evaluative concerns’. Dunkley et al. (2006) found that it is the evaluative concerns dimension that is linked to various psychopathological indicators.

Moreover, evaluative concerns are significantly linked to self-criticism, and it is the self-critical aspect of evaluative concerns that is particularly pathogenic. Sachs-Ericsson, Verona, Joiner, and Preacher (2006) found that children who are shamed by their parents (they use the term ‘verbally abused’) by being called stupid or bad may be especially vulnerable to develop self-criticism by easily internalizing these labels. They found that self-criticism fully mediated the relationship between parental shaming (verbal abuse) and depression and anxiety; a finding replicated by Irons et al. (2006).

[S]elf-criticism can emerge from many sources, e.g. from modeling (treating self as others have treated self), safety strategies/behaviours with hostile others, shame (Andrews, 1998; Gilbert, 1998), inabilities to process anger (Ferster, 1973), lack of internal schema of others as safe/supportive (Mikulincer & Shaver, 2004) and/or as a fear–anger/frustration response that acts as a warning in the face of threat (e.g., if you don’t work harder, lose weight, control your emotions no-one will love you). Although the threat-safety seeking aspects of self-criticism can vary, a common theme that links them may be the inability to self-soothe and be compassionate to self when under shame-focused threat.

- Gilbert, Paul, Procter, Sue; Compassionate Mind Training for people with High Shame and Self-Criticism: Overview and Pilot Study of a Group Therapy Approach; Clinical Psychology & Psychotherapy; Nov/Dec 2006; Vol. 13; Issue 6.

Personal Reflection Exercise #3
The preceding section contained information regarding the potential origins of self-criticism.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Polizzi, C. P., Baltman, J., & Lynn, S. J. (2019). Brief meditation interventions: Mindfulness, implementation instructions, and lovingkindness. Psychology of Consciousness: Theory, Research, and Practice. Advance online publication.

Rost, F., Luyten, P., Fearon, P., & Fonagy, P. (2019). Personality and outcome in individuals with treatment-resistant depression—Exploring differential treatment effects in the Tavistock Adult Depression Study (TADS). Journal of Consulting and Clinical Psychology, 87(5), 433–445.

Shanok, N. A., Reive, C., Mize, K. D., & Jones, N. A. (2020). Mindfulness meditation intervention alters neurophysiological symptoms of anxiety and depression in preadolescents. Journal of Psychophysiology, 34(3), 159–170.

Online Continuing Education QUESTION 17
In children, it was found that parental shaming, and depression and anxiety was mediated by which of the child’s behaviors? Record the letter of the correct answer the CEU Test.

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