Cognitive Behavioral Therapy: a Study of Its Application and Effectiveness

Shame is a feeling that most people will experience at some time in their lives, however, for some people, chronic shame can have some major effects on both psychological and physical wellbeing. Shame has been commonly linked to mental illnesses such as anxiety (Zhong, Wang, Qian et al., 2008), and depression (Cheung, Gilbert & Irons, 2003), as well as being shown to have effects on physiological health, such as having significant effects on immunological functioning (Dickerson, Kemeny, Aziz et al., 2004). Since shame can have such significant impacts on a person’s wellbeing, finding an effective intervention to treat and alleviate feelings of shame is vital. Many different psychological approaches have put forward approaches which may help to treat shame, in this particular essay, the focus will be specifically on cognitive behavioural therapy (CBT). The strengths and weaknesses of this approach will be analysed, looking at two prominent symptoms of shame – low self-esteem and social anxiety - evaluating how effectively CBT can be used to treat clients experiencing these symptoms, and how this may relate to the treatment of shame. CBT as a whole will also be evaluated, and an alternative form of treatment will be briefly discussed in order to fully assess how effectively CBT can be used as a psychological intervention for these clients.

In order to evaluate how effective CBT is at helping clients with shame, two of the main symptoms of shame will be looked at individually. Van Vliet (2008, p233) stated that “In particular, shame is elicited in response to social rejection and other events that threaten the individual’s self-esteem, social status, and sense of belonging”, and Gruenewald, Kemeny, Aziz & Fahey (2004) were able to find a distinct link between an increase in shame and a decrease in self-esteem. Therefore the first aspect which will be evaluated, is how effectively CBT can be used as a treatment of low self-esteem.

In 2003, Hall & Tarrier proposed a form of Cognitive Behavioural treatment to target low self-esteem (specifically for patients experiencing psychosis). They tested this method of CBT on a sample of patients, and found that, in comparison to patients who continued to receive their regular treatment with no CBT intervention, there was a clinically significant increase in self-esteem. Hall & Tarrier also measured the levels of self-esteem again three months after the treatment, and found that in the majority of cases, the benefits to self-esteem had been maintained. The results of this study suggest that CBT can be an effective intervention for improving clients’ self-esteem, which, given the strong links between low self-esteem and shame, would also suggest that this form of treatment would have a positive impact on clients experiencing shame. However, this study was very specifically focused on clients with psychosis. Although this treatment was shown to have strong benefits for the participants of this study, there is no way of knowing whether it would have the same benefits if used to treat otherwise healthy individuals. This lack of generalisability makes it difficult to fully evaluate how effective this treatment truly is at improving general self-esteem issues. As well as this, although the study was followed up three months after treatment, this is not strong evidence of a long term solution. Ideally for members of the general population experiencing shame, the treatment should be effective in the long term. If clients have to continue going back for treatment every three months, this would not only be an inconvenience, but could also begin to have an even more negative impact on their self-esteem, and lead to the feelings of shame growing stronger.

Another study conducted in 2007 (Taylor & Montgomery) looked at how efficient CBT was as a method of improving self-esteem among adolescents with depression. A literature review was carried out, examining how effective the treatment had been in two previous trials. Their research found that although CBT did lead to an increase in participants’ self-esteem, the increase was not clinically significant. They did, however, find that in a five week follow up, participants’ self-esteem had continued to rise. Although still not reaching significant levels, this does suggest the CBT may lead to a gradual increase in self-esteem, and so could potentially offer a long term solution for client’s experiencing shame. Unfortunately, as with the previously discussed study, this review was focused on a very specific group of clients, in this case focusing on adolescents aged 13-18. This, again, may mean that the findings of this study cannot be generalised to the wider population. Furthermore, this study also failed to look into the long term effects CBT had on self-esteem. Although their results showed that self-esteem did seem to be gradually rising, research was only followed up five weeks after treatment, and so it is unclear as to whether self-esteem would continue to rise to a steady level, or if it may begin to decrease again after time, which, as previously mentioned, could lead to further negative effects for client’s with shame. Finally, this review only looked at research from two previous studies. The conclusions drawn from this study would be much more reliable if they had drawn data from a wider range of sources, and so it may be necessary for further research to be conducted in order to fully evaluate how effective CBT can be at improving self-esteem, and so helping clients who are experiencing shame.

The second aspect of shame which will be examined is social anxiety, which can be both the cause of shame, and the result of shame. Pattison (2000) described the impact of shame as “..fear of being uncovered which produces a strong desire to be covered…perceived threat of public exposure”. If CBT can effectively alleviate social anxiety, and make a client feel more able to go out into the world instead of feeling they have to hide themselves, this should also help to alleviate the feeling of shame.

A study by Hedman, Ström, Stünkel, & Mörtberg (2013) examined the link between social anxiety disorder (SAD) and shame, and researched how effectively CBT treated participants with SAD, and how well it reduced feelings of shame. Their results showed that there was a strong link between SAD and shame, finding that participants with SAD had significantly higher levels of shame than the control group. It was also found that following CBT, symptoms of SAD were treated effectively, and feelings of shame were significantly reduced. The results of this research not only confirm that the treatment of SAD can also lead to a successful reduction in feelings of shame, but also show that CBT can be used to achieve this. However, the data used in this study was collected before, and shortly after receiving treatment. No follow up data was collected and so it cannot be said whether or not the effects of the treatment were long lasting, or for how long treatment would need to go on for in order to have a positive lasting effect on clients. As well as this, when testing to see whether CBT was an effective treatment, all participants with SAD received the same treatment, and so although a significant improvement was found, there is no control group to compare this with.

Given the apparent link between the treatment of social anxiety and a depletion of feelings of shame, previous studies investigating how effectively CBT can treat social anxiety may also serve as evidence of CBT’s effectiveness at treating client’s with shame. One such study conducted in 2002 (Heimberg), assessed how well CBT could treat symptoms of SAD both over the short term and the long term. It was found that patients reported less symptoms of SAD, and a higher quality of life six months after the end of treatment. However, although quality of life had improved, these participants still scored significantly lower than average, suggesting that although CBT may result in improvements for a client experiencing shame, it may not work as an effective long term solution as the client’s overall quality of life could still remain below average.

A further literature review conducted by Rodebaugh, Holaway, & Heimberg (2004) assessed the efficacy of CBT when treating children and adolescents with SAD. They found that across the literature, all CBT techniques resulted in a significant reduction in SAD symptoms both compared to pre-treatment, and in comparison to patients who had not yet received any treatment. They also found that on average, improvements were maintained for as long as twelve months after treatment ended. However, this study was focused specifically on the impact of CBT on children and adolescents, and so the results of the meta-analysis conducted may not accurately reflect the effects CBT can have on adults. As well as this, both Rodebaugh et al (2004), and Heimberg’s (2002) studies identified that CBT was most effective when clients expected the treatment to help. For those clients who were more sceptical about the effects treatment would have, the improvements they felt were often less significant. This may create an issue when it comes to treating clients who experience shame, as one of the key emotions associated with shame is hopelessness. If a client experiencing shame is already feeling hopeless, and feels that they are already beyond helping, CBT may not have as much of a positive impact on these clients as it would have on client’s who already believe CBT will help them.

Finally, the CBT approach as a whole will be examined. Mollon (2002a) stated that “Shame is a broken connection between one human being and others. A break of understanding, expectation and acceptance that is necessary for a sense of being a valued member of the human family….the cure for shame is empathy”. With this in mind, in order to assess how effective CBT can be when dealing with clients with shame, the use of empathy in CBT must be examined.

There are two main focuses of CBT: cognitive restructuring and behavioural activation (Nathan & Gorman, 2002). This is usually achieved through homework tasks given to the client after each appointment. A criticism of CBT therapists is that they can come across as overly critical or uncaring, presenting more of a teacher role than the role of an empathetic therapist, as described by Ryle (2012) in his critique of CBT. However, in an alternative review by Vyskocilova, Prasko & Slepecky (2011), cognitive behavioural therapists were described as showing “genuine empathy, respect, caring, regard, and accurate understanding.”. These conflicting responses may stem from differing forms of training, or could be due to individual differences among counsellors, as each counsellor may have a slightly different approach to working with their clients. Burns & Nolen-Hoeksema (1992) conducted a study to examine the role of empathy in CBT when treating clients with depression. They found that clients rated novice therapists as less empathetic compared to more experienced therapists, and showed significantly lower improvements as a result. This is, however, a dated study. The education and training therapists receive is constantly improving, and, since the more recent studies, such as those by Vyskocilova et al (2011) and Ryle (2012), are beginning to focus more on the role of empathy and other core conditions in the therapeutic relationship, it is likely that more recent training has focused on building these skills.

Relating this back specifically to clients who are experiencing shame, the research in this area shows some conflicting results. However based on Burns & Nolen-Hoeksema’s study, it would appear that experienced therapists are crucial when dealing with these particular clients, as empathy is a vital element in treating shame. As the core conditions of this approach do not focus specifically on the need for empathy, it could be that this approach is not the most suitable for these clients. Alternative approaches such as the humanistic approach, which was founded on core conditions such as empathy and unconditional positive regard (Rogers, 1959), may offer a more effective treatment for clients experiencing shame. This method of counselling allows the client to take control of their own therapy, as opposed to the structured, educational method that CBT often uses, and so this may prove more beneficial for clients experiencing shame.

To summarise, there is a range of research showing that CBT works as an effective form of counselling. There has been a direct connection made between the use of CBT as a psychological intervention and a decrease in feelings of shame (Hedman et al, 2013), as well as numerous psychological studies which have shown a significant reduction in symptoms and feelings associated with shame, as a result of participants receiving treatment through CBT. Looking at all this research as a whole, it is easy to conclude that CBT works as a psychological intervention. However, as has been discussed, many of these studies are focused on specific groups of people, which makes it difficult to fully evaluate how significant of an improvement CBT would have on members of the general population. There is a need for more research on otherwise psychologically healthy adults experiencing shame, in order to truly understand how well CBT could be used to treat these people. Additionally, there is a notable lack of long term research in this area. Only one study was found which provided data from twelve months after participants had completed their treatment, but the majority of research was concluded just a few months after treatment, or had no follow up data at all. Although all of the follow up data did show that the positive impacts of the treatment had been maintained or even increased further, more research could be done to investigate the long term effects of CBT. If this were done, it would be easier to draw a firm conclusion about the effectiveness of CBT, as although it may have significant positive effects immediately after treatment, if clients have to receive further treatment after a few months, it would not be considered an effective psychological intervention. Given the research data available, however, it would appear that the effects of CBT are long lasting, and seem to provide a long term, if not permanent, solution for clients. So, although the therapeutic relationship in this form of counselling may be in need of improvements due to some people feeling it lacks in empathy, overall it can be concluded that CBT does work as an effective psychological intervention for clients that experience shame, and has been consistently proven to have significant positive effects in these case.