key words: EMDR; Shame; Internalized Shame Scale, Self Esteem

Thirteen subjects were administered the Internalized Shame Scale (ISS) before and after EMDR therapy to determine whether Eye Movement Desensitization and Reprocessing (EMDR) significantly reduced internalized shame and increased self-esteem as measured by the ISS. While the study did not control for alternative treatment effects, age, diagnosis, SES, or ethnicity of subjects; statistical analysis indicated a significant decrease in internalized shame subscale scores and a significant increase in self-esteem subtest scores following treatment with EMDR. These results support the hypothesis that EMDR is an effective treatment for internalized shame, even when shame is not the identified target of treatment. These preliminary findings suggest that future research is warranted to explore the efficacy of EMDR in the treatment of internalized shame.

Internalized shame beleaguers many psychotherapy patients and remains an intractable treatment problem. Although much has been published about shame and self-esteem since 1980. For example, no clearly effective treatment has emerged that consistently results in shame reduction or the enhancement of self-esteem. This pilot study supports the utility of Eye Movement Desensitization and Reprocessing (EMDR) as a method of reducing internalized shame while increasing self-esteem. It is the first identified attempt in the field of published shame studies to support a specific treatment for internalized shame.

The experience of shame can range from a transitory affect that is easily managed to a consistent and persistent mood that so clouds a person's experience that it is considered an integral part of the personality. The concept of internalized shame depicts an extreme and intense sense of shame as a core chronic aspect of identity, as distinct from the emotion of shame, which although sometimes intense, is transitory. Internalized shame permeates a person's life as the filter through which all experience is perceived (Spero, 1984; Thrane, 1979), and seduces the person into describing (and believing) him- or herself as bad, dirty, worthless, hopeless, and, perhaps worst of all, immutable (Balcom, 1991). A person suffering from internalized shame is typically prone to misread social cues and communication, to expect the worst in all situations as their due, and to see insult and injury in benign or positive social exchanges. Schore (1994) describes how shame moves from the affect of shame to internalized shame, emphasizing attachment failures in early care giving as a critical developmental experience.

In clinical settings, internalized shame can present itself as a chief complaint or a secondary complaint. Shame can cause other symptoms, as when shame leads to elaborate rituals intended to keep others form seeing one's "badness," as well as result from other symptoms (e.g. a person with a phobia of public restrooms goes to great lengths to keep secret his fear). Virtually all traumatized patients have some degree of internalized shame (Courtois, 1992). In addition, internalized shame is often a key component of addictions, anxiety disorders, depression, major mental illness and personality disorders.

Self-esteem is the opposite of internalized shame (Cook, 1991, 1989). It represents "an individual's sense of personal worth that is derived more from inner thoughts and values than from praise and recognition from others" (Barker, 1987). Thus, shame reduction and self-esteem enhancement can potentially benefit many patients regardless of whether shame is addressed directly or indirectly in treatment.

Until now, the reduction of internalized shame has involved a combination of numerous psychotherapeutic techniques. Therapy often begins with the identification of shame as an ancillary treatment issue, and then proceeds to the development of self-intervention skills. These skills focus on 1) preventing further experiences of internalized shame, and 2) on learning self intervention tactics to reclaim self-esteem while in a shame experience. To date, clinical reports on the effectiveness of these interventions have not been validated by research (Alonso & Rutan, 1988; Harper & Hoopes, 1990; Jordan, 1989; Krugsman, 1995; Osherson & Krugsman, 1990: Pines, 1995; Potter-Efron, 1989: Scheff & Retzinger, 1991; Warton, 1990).

Current publications on shame address theoretical, developmental, and treatment issues, while they often include case examples, they do not include research to support the effectiveness of the proposed treatment models (Balcom, Lee, & Tager, 1995; Catherall, & Shelton, 1996; Fossum & Mason, 1986; Lansky, 1992; Lee & Wheeler, 1996; Lewis, 1992; Miller, 1985; Morrison, 1989; Nathanson, 1987; Potter-Efron, 1989; Retzinger, 1991; Schenk & Everingham, 1995; Wurmser, 1981).

Although the treatment of shame with EMDR has not been studied to our knowledge, numerous recent wait-list controlled and treatment comparison studies support the use of EMDR for treating Post-Traumatic Stress Disorder (PTSD) and it's symptoms (Carlson, Chemtob, Rusnak, Hedlund, & Muraoka, 1988; Marcus, Marquis & Sakai, 1997; Rothbaum, 1997; Scheck, Schaeffer & Gillette, 1998; Wilson, Becker & Tinker, 1995; Wilson, Silver, Covi, & Foster, 1997).

EMDRs effectiveness in treating symptoms of PTSD, and the high correlation between trauma and shame (Catherall & Shelton, 1992; Courtois, 1992; Wong & Cook, 1992), suggest that EMDR could be an effective treatment for reducing shame and enhancing self-esteem. The link between shame and trauma has been noted clinically and incorporated into several psychological and neuropsychological models (Courtois, 1992 ; Nathanson, 1992; Tompkins, 1987; van der Kolk, 1996, 1994). We suggest that EMDR could reduce the shame that often co-exists with PTSD and other diagnoses.

Affect Theory as developed by Tompkins (1962, 1963) and furthered by Kaufman (1985, 1989) and Nathanson (1992); Accelerated Information Processing Theory-a conceptual model for understanding EMDR (Shapiro, 1995);
and studies that compare traumatic memory with non-traumatic memory (van der Kolk, 1996), share a conceptual  understanding of how distressing material is experienced, stored, recalled, and processed.

Affect Theory states that internalized shame is stored in memory in the form of images, emotions, thoughts, and body sensations that result from specific scenes in which the client experienced shame. "It is through imagery (encompassing visual, auditory, and kinesthetic dimensions) that the self internalizes experience. What is internalized are images or scenes that have become imprinted with affect" (Tompkins, 1987). These scenes are the "building blocks of personality," according to Tompkins, and lead to life scripts that dictate the course of the client's life (Nathanson, 1992).

Similarly, the Accelerated Information Processing model asserts that distressing experiences are held in memory in state-specific form with a network of associations including the client's emotional and cognitive state of mind at the time of the trauma (Shapiro, 1989). For example, when a person experiences a traumatic event such as a fire, the sight of flames, thoughts such as "I'm going to die," feelings of distress, shock and terror, and racing heart and heat sensations are linked and stored, unintegrated in memory. A trigger or reminder of the event that shares some aspect of the event (e.g., the smell of smoke) can evoke the traumatic memory in such detail that it can feel as thought the trauma is recurring in the present even long after the event. Once such a memory has been triggered, it can be difficult for a client to connect with a higher-functioning, more rational assessment of the present (Shapiro, 1995).

Contemporary research on memory, with an emphasis on the emotional components of memory, inform us that traumatic memories tend to be stored in the right hemisphere of the brain (Bergman, 1998; Parnell, 1999; Petrides, Alivistos,  Meyer, & Evans, 1993; Schiffer, 1998). Shame and other intense emotional memories also seem to be stored in the right hemisphere (Cacioppo, Klein, Berntson, & Hatfield, 1993; & LeDoux, 1993). In addition, traumatic memories disrupt physical functioning, especially the ability to return to normal baselines after arousal (van der Kolk, 1994). Concurrent with the storage and arousal aspect of memory is the inability to bring left hemisphere capabilities into action (Cacioppo, Klein, Berntson, & Hatfield, 1993; Pitman & Orr, 1995; Reisberg & Heuer, 1995; Schore; White, 1995). Bergmann (1998) discusses the possibility of neurobiological changes occurring during and after EMDR treatment.

"Processing" in EMDR begins when the therapist asks the client to recall a traumatic event by reconnecting with the thoughts, feelings, body sensations and images associated with the memory. Affect Theory predicts that shame affect could be one aspect of the traumatic memory. Indeed, the core beliefs surrounding shame as outlined by Tompkins and Nathanson correspond to the core beliefs frequently offered by patients in EMDR. In EMDR treatment, when clients are asked what negative belief about themselves is associated with a traumatic event, shame-based statements often emerge: 'I am unlovable,' ' I am weak,' ' It's my fault,' ' I am bad;'. Each of these are internalized shame referential statements due to the self judgement involved.

Given these conceptual models as a backdrop, we speculate that as distressing memories are accessed, processed and thus integrated in the course of EMDR treatment, and as the affects associated with the distressing memories lose their intensity, the internalized shame associated with those affects will also be reduced. Additionally, we assume that a new neural and associative network of memory and experience develops through EMDR treatment. We assume that as shame linked to distressing experiences decreases and as a person's assessment of past experience changes, the emotional and imagistic template they  bring to new experience will allow for an increase in the presence of positive affects and an enhancement of self-esteem.

Past research has used the Internalized Shame Scale(ISS) (Cook, 1989) to assess levels of internalized shame in clients with addictive and affective disorders (Cook, 1991), and with PTSD (Wong and Cook). In the model proposed by Cook, self-esteem is enhanced when shame is reduced, and as shame is reduced self-esteem increases (Cook, 1989; Mruk, 1995). The current study uses the ISS as measurement before and after EMDR treatment to determine whether EMDR is significantly associated with reduced internalized shame and increasedself-esteem.

The sample was recruited from outpatient psychotherapy practices in a large urban setting. Subjects were recruited by the authors during 1997 as part of routine evaluation for EMDR treatment. Recruitment was non-random and participation in the study was not controlled by age, sex, diagnosis, number of treatment sessions, or other factors. Subjects ranged in age from 22 to 60, were all Caucasian, and suffered a variety of symptoms and diagnoses for which they sought EMDR. Diagnostic data was not obtained. There were 3 men and 10 women.

Instrument

The Internalized Shame Scale (ISS) consists of two subscales which measure internalized shame and self-esteem. The 30 item scale has 6 items that are positively worded references to self-esteem, and 24 items that are negatively worded references to internalized shame. The range of scores on the internalized shame subscale is 0-96, on this subscale scores of 50 or above indicate "painful, possible problematical levels of internalized shame." Self- esteem subscale scores range from 0 to 24 with scores of 18 or higher "indicative of positive self-esteem." A Likkert scale (0 to 5) for each item allows for arithmetic scoring for both subscales. Reliability (.95), validity, and test-retest coefficients (.84) of the scale are well documented by Cook (1989).

Therapists

Treatment was provided by two EMDR Level II trained clinicians (first and second authors of this report) who are licensed in social work and psychology. One clinician treated five subjects, the other treated eight subjects.

Procedure

Subjects were asked by the treating clinician to complete the ISS prior to the first EMDR treatment session (pre-test)
and again after the last EMDR treatment session (post-test). Treatment consisted of two to thirteen sessions of EMDR. EMDR treatment followed the standard protocol developed by Shapiro (1995). After the clinician established rapport and guided the subject to visualize a "safe place," the subject was asked to recall an upsetting memory and the picture representing the worst aspect of the memory. The subject was then asked what negative belief about themselves went along with that image. Next, the subject was asked what she would prefer to believe about herself, and to rate how true that positive statement felt on the Validity of Cognition Scale (VOC), ranging from 1, completely false, to 7, completely true. Then, holding the picture in mind and the negative belief, the client was asked to identify the associated feeling and body sensations and to rate the intensity of the
memory on the SUDs (from 0, no disturbance, to 10, the worst disturbance). The subject was then instructed to hold these aspects of the disturbing memory while following the movement of the therapist's fingers (or light bar). After each set of eye movements, the client was asked, "what are you noticing now," and after a brief explanation, eye movements were continued. The therapist used these brief explanations as a guide to the client's experience and occasionally asked questions or made comments that would facilitate the processing. This continued until the VOC had risen to 6 or 7 and the SUDs had dropped to 0 or 1. At the end of each session, clients were lead through a relaxation exercise if they were still distressed.

Successive sessions repeated this same process until the presenting symptoms that had lead the patient to seek treatment were sufficiently alleviated. The time period between sessions was typically one week, and sessions ranged in duration from 50 to 90 minutes. At the end of the treatment, subjects were re-administered the ISS (post-test).

Hypotheses

EMDR treatment will result in

1) significant reduction of internalized shame, and

2) significant increase in self-esteem as measured by the ISS at the .05 level of significance.

Statistics

The limited sample size made multi-factorial analysis inappropriate. Thus, univariate and bivariate analyses using a paired two-tailed t test were applied to assess significance of the change observed between pre- and post-ISS subscale scores.

Results

At intake, subjects' arithmetic raw scores on the shame subscale ranged from 27 to 84, and scores on the self-esteem scale ranged from 5 to 21. A paired t test showed a significant decrease in internalized shame subscale between the pre- and post-test means (45.96 to 33.58), as well as a significant increase in self-esteem subscale pre- and post-test means (from 14.92 to 17.30). Table 1 also displays the range of scores around the mean. The range of scores on both post-test subscales illustrate that some subjects continued to exhibit clinical levels of internalized shame and reduced self-esteem after the intervention, while other respondents showed improvement on these subscales after EMDR treatment.

Table 1. Change in Internalized Shame and Self-Esteem Between Pre- and Post-Tests
_________________________________________________________
                                            Internalized Shame                 Self Esteem
                                                  (n=13)                                 (n=13)
                                            ___________________________________

T-test mean Pre-test                     45.96                                  14.92
(range)                                   (30.68-61.24)                     (10.35-19.49)

T-test mean Post-test                    33.57                                  17.30
(range)                                    (12.96-54.20)                     (11.39-23.21)

p values                                        .0098                                  .0068
__________________________________________________________

Please note: the depiction of the data in the tables is not in accordance with APA format. When statistics are reported, for example, t-tests, the appropriate description is the the value of the coefficient (in this case, the t statistic), as well as the degrees of freedom and p-value are reported. So, if someone did a paired-samples t-test, they might report the results as follows: "Paired sampled t-tests show a significant difference from pre - test to post-test on both measures, as depicted in Table 1 (standard deviation statistics should also always be reported with means)..
_________________________________________________
                                            Group 1                Group 2
                                        _____________________________

Pre-test mean and SD            45.96 (SD)            14.92 (SD)
Post-test mean and SD           33.57 (SD)            17.30 (SD)
t value                                   xx (p = .009)           xx (p = .006)
df                                                xx                        xx
__________________________________________________

NOTE Table 2 should similarly include values of the t statistic, degrees of freedom,  and standard deviations.
 

Because Table 1 pooled all respondents, whether or not they improved on one or both of the subscales after EMDR treatment, we were interested in knowing if those who improved on both tests showed significantly greater gains than those who did not improve on both subscale.

Table 2 displays data for two groups of subjects. Group 1 consists of subjects (n = 9) who exhibited significant change in the desired direction on both subscales (a decrease in internalized shame and an increase in self-esteem). Group 2 consists of subjects (n = 4) who improved on one subscale only or had negative change on one or both scales.

At pre-test, there was no significant difference in the mean scores on the internalized shame and self esteem subscales for Groups 1 and 2. The change in pre- and post-test mean scores on both subscales was statistically significant for Group 1 (p = .002 and p = .001,respectively) but not for Group 2 (p = .475 and p = .302, respectively). The findings for Group 2 suggest that for some subject exposure to the intervention had little effect on internalized shame and self-esteem, between pre- and post tests.

Table 2. Comparison of Participants Who Did and Did Not Change in Internalized Shame and Self-Esteem Pre- to Post-Test
______________________________________________________________________
                                                     Group One^a                     Group Two^b
                                                          (n = 9)                                  (n = 4)
                                           ________________________________________________

                                                Internalized     Self                  Internalized         Self
                                                Shame            Esteem             Shame                Esteem
_______________________________________________________________________

T-test mean Pre-Test                 45.55            15.55              46.87                   13.50

T-test mean Post-Test                27.94           19.22               46.75                    13.00

t value ? p values                         .002              .001               .475                      .302
________________________________________________________________________
^a Improved on both subscales
^b Negative change on one or both subscales, or improvement on one subscale only

This was an exploratory pilot study to test the hypotheses that EMDR treatment in outpatient psychotherapy may reduce internalized shame and enhance self-esteem. In a study of 13 subjects, the data suggest that EMDR treatment in outpatient psychotherapy may reduce internalized shame and enhance self-esteem for most participants. As shown in Table 1, for the group as a whole, the means of both subscales showed a significant shift in the expected direction between the pre-and post-tests.

While these results are promising, it is important to note that not all patients showed improvement of self-esteem or reduction of internalized shame. Some patients exposed to EMDR treatment experienced an increase in internalized shame and a decrease in self-esteem or improvement on one subscale only, although the change in mean scores on the subscales was not statistically significant for this group (Table 2, Group 2). Further research, with a larger subject population, would clarify why some subjects do not respond to EMDR treatment as a therapeutic intervention for treating internalized shame and low self-esteem. Due to the absence of diagnostic data, the groups could not be compared on that dimension.

Several limitations of this study should be noted. First, this was a small, non-random sample without a control group. There is no way of knowing whether the significant factor for change in scores was EMDR or some other element of the therapy. Second, other intervening variables such as time (length of treatment or time between pre/post tests), age, diagnosis, medication, or gender may account for some of these results. Finally, although both clinicians are well-trained and experienced in using EMDR, we did not assess for fidelity of the EMDR treatment.

Even with the above caveats, this study supports the use of the ISS in clinical settings as a possible measure for treatment outcome related to internalized shame and self-esteem. The ISS is easy to administer and score, and yields information valuable to assessing the effectiveness of treatment. Although this is a preliminary study, results are sufficiently encouraging to support further exploration in applying EMDR to the treatment of internalized shame. A study with a larger sample size to replicate these findings is necessary. It would also be of interest to determine additional influential factors such as diagnosis, age, sex, and the number of EMDR treatment sessions.

Another direction for future research would be to directly target shame experience with EMDR for patients presenting with internalized shame or low self-esteem to determine whether doing so would produce the same beneficial results (as it has with indirect application). This could be achieved by applying the standard EMDR protocol as outlined by Shapiro to process memories that evoke shame, or by utilizing the Resource Installation Protocol described by Leeds (1997, 1998). The latter protocol is a new application of EMDR that shows promising clinical results, but which has yet to be validated by research. Additionally, the recommendation of Zangwill (1994) on using sounds (instead of eye movement) with the patient's eyes closed may provide further insight into effective techniques within EMDR.

Finally, as technology designed to observe neuroanatomy and its functions improves, it would be interesting to identify specific sites in the brain where shame is activated and match these with the sites in the brain that EMDR influences in an effort to refine the application of EMDR to the treatment of internalized shame.

This pilot study suggests that EMDR reduces internalized shame and increases self-esteem for patients in outpatient psychotherapy. Although the small sample size precluded multi-variate analyses these results add to the expanding literature on EMDR and on the treatment of internalized shame. The most promising result from this preliminary report is that for the first time a specific treatment method is shown to be of value in caring for patients suffering from debilitating shame and low self-esteem.

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Dennis Balcom,  MSW., is in private practice:  124 Harvard St.#7A, Brookline, MA 02446-6439. Electronic mail may be sent to Dabalcom@cs.com.

Elizabeth Call, PsyD., Harvard Medical School, Department of Psychiatry, Massachusetts General
Hospital Erich Lindemann Center, 25 Staniford St. Boston, MA 02114, 617 727-5500 x 167.

Deborah N. Pearlman, PhD., Brown University Department of Community Health, Providence, RI 02912

Volume VI, Issue 2, Article 2 (August, 2000)