Shame and Other Self-Devaluing Schemas in Suicidal Persons

Those who treat suicidal patients are often startled by the depth and intensity of the anger patients express toward themselves. When asked to list their reasons for wanting to die, many respondents listed negative self-appraisals, such as “I’m worthless, “I’m a piece of crap,” or “I don’t deserve to live” (Madsen & Harris, 2021, p. 5).

These negative trans-diagnostic self-appraisals appear in depressive, anxiety, and other disorders and could reflect shame, self-disgust, or perfectionism. Although distinct in some ways, these schemas, or enduring ways of thinking about oneself, have the common feature of disapproving or devaluing oneself (see Table 1 for a brief description of these patterns). These ways of viewing oneself can become entrenched and automatic ways that patients view themselves or interpret their life experiences. Psychotherapists can better help their suicidal patients if they understand these self-disapproving schemas, their accompanying emotions, and healthy alternatives.

Table 1

Shame versus Guilt

Shame and guilt may both arise when an individual believes they have violated a rule of social behavior. However, they differ in how individuals respond to their perceived transgressions. Those who feel guilty feel motivated to apologize, repair the harmed relationship, or make amends for their behavior. In contrast, those who feel shame believe that their offensive actions represent something intrinsically wrong with themselves and that they are so defective that they can never sufficiently apologize or make amends for their behavior. Shame is concerned with the individual’s totality and perceptions of their worth. It involves a global and stable negative belief about themselves and concentrates on their deficiencies and shortcomings. Those who feel shame tend to withdraw, escape, or otherwise avoid others (Swee et al., 2021).

Those who feel guilt have some self-compassion, while those who feel shame lack this tendency. A person with guilt, for example, may believe it is only human to make mistakes, that forgiving oneself is healthy, and that it is unproductive to be consumed by negative emotions. In contrast, a person with shame is likelier to ruminate and show cognitive inflexibility (Cenker et al., 2023). Shame causes or increases the emotional burden on suicidal patients, discourages them from seeking support from others, and increases their overall risk of suicide. Patients who feel shame may have difficulty sharing their feelings with others. Even when they do enter psychotherapy, they may be less likely to disclose the behaviors that led to shame, including the shame of having suicidal thoughts (Knapp, 2023).

Self-stigma may occur as a result of shame. In addition to having shame over past behaviors, patients may also feel ashamed of having suicidal thoughts in general. Society often stigmatizes people with suicidal thoughts as weak, cowardly, or selfish (Joiner, 2010), and some suicidal persons may have internalized these beliefs. This self-punishment tends to increase the frequency of suicidal thoughts (Tucker et al., 2017) and the risk of suicide (Mayer et al., 2020). As stated by O’Connor, “When stigma increases, help-seeking declines, ignorance flourishes, and deaths soar” (2021, p. 79).

Self-Disgust versus Self-Compassion

Disgust can be adaptive because individuals want to avoid obnoxious, smelly, offensive, and potentially harmful objects or substances, such as spoiled fruit or rotten carcasses. Self-disgust is a maladaptive variant of disgust. Self-disgust is not defined consistently and could refer to an emotional state or an enduring way of thinking about oneself (Clarke et al., 2019). It overlaps with shame but involves unique physiological reactions. As one research participant stated, “I’m feeling depressed, you feel that cramp in your stomach, and it feels like I’m about to throw up or something” (Mason et al., 2021, p. 584).

Those who feel self-disgust tend to distance themselves from others (Schienle et al., 2020). Self-disgust appears to have a reciprocal relationship with self-harm, with self-disgust preceding acts of self-harm and acts of self-harm contributing to a feeling of self-disgust (Clarke et al., 2019). This finding makes sense because those who feel self-disgust and want to avoid others may easily develop perceived burdensomeness or a sense that others would be better off if they died (Mason et al., 2021).

Perfectionism versus Conscientiousness

Perfectionism is the “combination of excessively high personal standards and overly critical self-evaluation” (Curran & Hill, 2019, p. 410). Perfectionism is a maladaptive expression of conscientiousness. Being conscientious means being responsible, diligent, or careful. Perfectionism differs from conscientiousness because it involves the continual, unfair, unforgiving, and unrelenting negative evaluations of one’s behavior. The standards are so high that one can never reach them. Whereas conscientiousness prompts people to reach higher levels of achievement or virtue, perfectionism may inhibit their ability to reach these goals. High standards only uplift if they are combined with self-compassion. High standards without self-compassion predispose a person to feelings of failure and inadequacy. As stated by Barcaccia et al. (2019), “The more you judge the worse you feel” (p. 33).

Perfectionism can take different forms, such as self-oriented perfectionism or holding oneself to unreasonably high standards. However, socially prescribed perfectionism – “the tendency to believe others have high or unrealistic expectations as well as a belief that one has failed to meet these high expectations” (Moscardini et al., 2023, p. 268) – is the form of perfectionism that is most strongly linked to suicidal thoughts.

It is easy to see how socially prescribed perfectionism could impair one’s relationship with others. Suppose one sees others as a source of continuing and unfair criticism. In this case, it is reasonable to believe that those with socially prescribed perfectionism are at risk of strained interactions with others and would be less likely to seek emotional support due to feeling inhibited about sharing their self-doubts, fears, or concerns.

Intervention Options

Often, patients attempt to regulate the feelings caused by self-devaluing schemas by avoiding others or through emotional suppression. Neither of these strategies is effective, and emotional suppression may even heighten negative emotions in the long run (Tucker et al., 2017). The psychotherapist’s goal is to help patients develop better strategies for managing their emotions, often through cognitive reappraisals or rethinking their assumptions about themselves.

Some universal elements of good psychotherapy appear to address these harmful schemas. For example, psychotherapists who present themselves as caring and nonjudgmental may convey to patients that whatever they did—or think they did—never negates their intrinsic worth as a person. This includes the process of validation. This does not mean that the psychotherapist agrees with their patient’s ideas of killing themselves but rather understands how – given their patient’s life experiences and assumptions – their patient concluded that suicide should be an option for them (Schecter & Goldblatt, 2011). Of course, interventions are best when they are tailored to individual needs (Norcross & Cooper, 2021), and psychotherapists may need to tailor their interventions to address their patient’s unique, harmful self-devaluing schemas.

The informed consent process can be utilized as an initial intervention strategy containing psychotherapeutic elements. This can include expressing patients’ involvement in as much of the clinical decision-making as possible, relying on them as experts on their own experience, and expecting feedback from them concerning their perceptions of the nature of psychotherapy and their progress (Knapp, 2024).

Although cognitive reappraisals may occur in many forms of psychotherapy, interventions that focus on self-compassion or mindfulness appear especially appropriate for patients with self-devaluing schemas (Flett et al., 2021; Stynes et al., 2022). These may increase patients’ self-acceptance and psychological flexibility and reduce their isolation from others. Some elements of self-compassion include avoiding strong identification with any emotion, accepting that some aspects of life are universal (e.g., everyone may feel self-disgust at some point), and striving for self-forgiveness. Mindfulness-based interventions, such as compassionate mind training, mindfulness-based stress reduction, or mindfulness-based cognitive therapy, may increase psychological flexibility by helping patients identify thoughts and feelings in the present and consider alternative ways of dealing with them (Flett et al., 2021; Stynes et al., 2022).

Finally, self-devaluing schemas are intrapersonal events with interpersonal consequences. Reducing their negative impact may help patients become more open in their relationships with others, decrease social isolation and avoidance, and help them develop meaningful social relationships that will enrich their lives and provide a buffer against suicide attempts.

Practice Pointers

• Psychotherapists should be aware of the self-disapproving schemas (shame, self-disgust, and socially prescribed perfectionism) when treating suicidal patients.

• Shame and other self-devaluing schemas may create barriers between patients and others, including a reluctance to be open with their psychotherapists.

• Psychotherapists can reduce the impact of shame by approaching their patients with a caring, nonjudgmental, and curious attitude and using interventions that focus on self-compassion or mindfulness.