A Review of Client Self-Criticism in Psychotherapy

Abstract

Research on the construct of self-criticism has been gaining attention in the psychopathology and psychotherapy literature. The aims of this review are to provide an integrated theoretical and empirical understanding of client self-criticism and its implications for psychopathology and processes of self-critical change. Cognitive, emotion-focused, and psychodynamic therapy approaches are reviewed to highlight the ways in which self-criticism is addressed across different psychotherapies. Implications for treatment are put forward based upon the strengths of the different approaches in developing a self-protective and self-compassionate stance toward self-criticism. (PsycINFO Database Record (c) 2013 APA, all rights reserved)

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A Review of Client Self-Criticism in Psychotherapy
Divya Kannan
Vanderbilt University
Heidi M. Levitt
The University of Massachusetts Boston
Research on the construct of self-criticism has been gaining attention in the psycho-
pathology and psychotherapy literature. The aims of this review are to provide an
integrated theoretical and empirical understanding of client self-criticism and its
implications for psychopathology and processes of self-critical change. Cognitive,
emotion-focused, and psychodynamic therapy approaches are reviewed to highlight the
ways in which self-criticism is addressed across different psychotherapies. Implications
for treatment are put forward based upon the strengths of the different approaches in
developing a self-protective and self-compassionate stance toward self-criticism.
Keywords: psychotherapy research, self-criticism, client self-criticism, psychotherapy integra-
tion
Within the last two decades, research on the
construct of self-criticism has been gaining at-
tention in the psychopathology and psychother-
apy literature. The literature indicates that self-
criticism often is encountered in clients who are
dealing with psychological difficulties such as
depression, anxiety, eating disorders, substance
abuse, personality disorders, suicide, and inter-
personal problems (Bergner, 1995;Blatt, 1974;
Cox, Enns, & Clara, 2002;Firestone, 1988;
Gilbert & Irons, 2005). Self-criticism is thought
to be a phenomenon that cuts across culture,
race, class, and gender (Whelton & Henkelman,
2002). Self-critical people hold negative beliefs
about themselves that either surface at different
points in their lives or are maintained in a con-
sistent manner across time (Blatt, 1974;Whel-
ton, Paulson & Marusiak, 2007). Although self-
criticism may be experienced universally, it also
can contain differences in its form, severity, and
consequences for each individual (Whelton &
Henkelman, 2002). The focus of this paper is on
self-criticism as a conscious evaluation of one-
self that can be a healthy and reflexive behav-
ior, but also can have harmful effects and con-
sequences for an individual. This definition was
drawn from psychotherapy researchers’ writ-
ings on self-criticism and positions the meaning
of self-criticism on a continuum of healthy to
maladaptive aspects of experience (Blatt, 1974;
Chang, 2008;Gilbert & Irons, 2005;Shahar,
2001;Whelton & Greenberg, 2005).
The Role of Self-Criticism in
Psychopathology and Psychotherapy
The examination of self-criticism in psycho-
pathology is focused upon the literature related
to depression and perfectionism, because de-
pression and perfectionism have been theorized
as being characterized by strong self-critical
responses. The review of the psychotherapy lit-
erature documents the relationship between
self-criticism and therapy alliance and outcome.
Self-Critical Processes and Depression
Self-criticism is most often described in the
literature as a dimension of depressive vulner-
ability or a component of depression (Blatt,
Quinlan, Chevron, McDonald, & Zuroff, 1982;
Carver & Ganellen, 1983;Gilbert, Clarke,
Hempel, Miles, & Irons, 2004;Klein, Harding,
Taylor, & Dickstein, 1988;Rector, Bagby, Se-
gal, Joffe, & Lefitt, 2000;Shahar, 2001;Whel-
ton & Greenberg, 2005). However, it is impor-
tant to note that self-criticism is not exclusive to
Divya Kannan, Psychological & Counseling Center, Van-
derbilt University; and Heidi M. Levitt, Department of
Psychology, The University of Masachusetts Boston.
Correspondence concerning this article should be ad-
dressed to Divya Kannan, Vanderbilt Psychological &
Counseling Center, 2015 Terrace Pl., Nashville, TN 37203.
E-mail: divya.kannan@vanderbilt.edu
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Journal of Psychotherapy Integration © 2013 American Psychological Association
2013, Vol. 23, No. 2, 166–178 1053-0479/13/$12.00 DOI: 10.1037/a0032355
166

depression. For instance, self-criticism has been
found to be a predictor of eating-disorder di-
mensions (Fenning et al., 2008) as well as the
outcome of borderline personality treatments
(Meares, Gerull, Stevenson, & Korner, 2011)
and is a major component of anxiety and per-
sonality-focused research (Dunkley, Zuroff, &
Blankstein, 2006;Frost, Heimberg, Holt, Mat-
tia, & Neubauer, 1993;Hewitt & Flett, 1991;
Shahar, Blatt, Zuroff, & Pilkonis, 2003,Shahar,
Blatt, Zuroff, Krupnick, & Sotsky, 2004).
Much of the research relating self-criticism to
depression originated from Sidney J. Blatt’s
psychodynamic conceptualization of depression
(1974). Subsequent research has found that clin-
ically depressed populations exhibit higher lev-
els of self-criticism than normal controls (Klein
et al., 1988;Luyten et al. (2007). In addition,
self-criticism (and trait dependency) also has
been associated with the recurrence of depres-
sive episodes (Mongrain & Leather, 2006).
Some researchers also have begun to examine
the forms of rumination (i.e., brooding) that are
most linked to suicidality (O’Connor & Noyce,
2008).
Self-Critical Perfectionism and Coping
Although perfectionism can have positive
consequences for individuals, perfectionistic
behavior can be harmful, especially when those
behaviors are accompanied by unrelenting self-
criticism and negative self-evaluation. Although
there is some consensus in the literature on the
development of maladaptive perfectionism
(Shafran & Mansell, 2001), three main dimen-
sional models of perfectionism have been most
widely used thus far, two of which have the
identical name; the Multidimensional Perfec-
tionism Scale as developed by (a) Frost and
colleagues (1990), and by (b) Hewitt and Flett
(1991), and (c) The Almost Perfect Scale
(Slaney & Johnson, 1992;Slaney, Rice, Mob-
ley, Trippi, & Ashby, 2001). Multiple dimen-
sions of perfectionism are assessed across these
measures, such as excessive concern over mak-
ing mistakes, high personal standards, a need
for order and organization, and self- versus oth-
er-oriented perfectionism.
Dunkley and Kyparissis (2008) conceptual-
ized self-critical perfectionism as “constant and
harsh self-scrutiny” and “concerns about others’
criticisms” (p. 1296). They found that individ-
uals that had higher levels of self-critical per-
fectionism described themselves as having feel-
ings of guilt, sadness, hopelessness, loneliness,
and low positive emotion. They also reported
being sensitive to ridicule and expressed being
cynical and skeptical. Dunkley, Zuroff, and
Blankstein (2006) found that self-critical com-
ponents of perfectionism significantly predicted
daily stress, avoidant coping mechanisms, low-
perceived social support, negative affect, and
low positive affect. Other correlational research
also has provided results consistent with these
findings too (Flett, Hewitt, Blankstein, & Gray,
1998; Gilbert, Baldwin, Irons, Baccus, &
Palmer, 2006). Self-critical perfectionism has
also been related to maladaptive coping (i.e.,
self-critical perfectionists responded to stressful
situations with self-blame, engaged in other
tasks rather than the task at hand, and used
fewer problem-oriented strategies to cope with
stress). The findings from the above studies
suggest that though perfectionist striving can
have positive outcomes for performance, ac-
companying self-criticism can hamper individ-
uals’ sense of efficacy and increase self-blame,
especially after a perceived stressful or failed
experience.
Accordingly, perfectionism and depression
can be intertwined. Research from the United
States Department of Health and Human Ser-
vices, National Institutes of Health, National
Institute of Mental Health Treatment of Depres-
sion Collaborative Research Program demon-
strated that perfectionism was negatively re-
lated to outcome (Blatt, Zuroff, Quinlan, &
Pilkonis, 1996;Krupnick et al., 1996). Zuroff et
al. (2000) examined the relationships among
perfectionism, perceived relationship quality,
and the therapeutic alliance. The results indi-
cated that the patient contribution to the alliance
and the perceived quality of the therapeutic
relationship were independent predictors of out-
come and perfectionistic patients showed
smaller increases in the patient-alliance factor
over the course of treatment. Furthermore, the
negative relation between perfectionism and
outcome was mediated by perfectionistic pa-
tients’ failure to develop stronger therapeutic
alliances.
The research reviewed in this section sug-
gests that clients with disorders associated with
self-criticism are likely to have difficulty con-
necting with others and to experience psycho-
167CLIENT SELF-CRITICISM
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logical distress. The next section reviews re-
search on the relationship of self-criticism
itself to psychotherapy alliance and treatment
outcome.
The Relationship Between Self-Criticism
and Therapeutic Alliance and Outcome
The therapeutic alliance refers to the col-
laborative aspect of the working relationship
between client and therapist, in which they
join together to negotiate the tasks and goals
of therapy (Horvath & Symonds, 1991). Psy-
chotherapy research has documented the
importance of the working alliance and its
contribution to psychotherapy process and
outcome (Ackerman & Hilsenroth, 2001). Re-
cent efforts at examining the effects of self-
criticism on therapeutic alliance suggest that
self-criticism might act to impair the alliance.
Whelton et al. (2007) examined the relation-
ship between self-criticism and the therapeutic
alliance in 169 clients attending a community
clinic. Self-criticism was positively correlated
with clients’ hostile mood state and negatively
correlated with their ratings of positive affect
(as measured by the Visual Analogue Scale
(VAS), Albersnagel, 1988), even at 9 and 12
weeks of counseling, respectively. Client rat-
ings from the Working Alliance Inventory
(Horvath & Symonds, 1991) were negatively
correlated with self-criticism, suggesting that
the greater an individual’s level of self-
criticism, the more negatively they rated their
relationship with the therapist. When they con-
trolled for the effects of hostility and positive
affect, self-criticism no longer predicted work-
ing alliance, suggesting that levels of hostility
and positive affect accounted for the working
alliance scores at certain sessions.
Janzen (2007) conducted a qualitative analy-
sis using the interpersonal process recall
method (Kagan, 1975) to examine self-critical
processes that clients engage in during therapy.
An in-depth phenomenological analysis re-
vealed that participants constantly evaluated
therapists and their therapy experiences. They
did not easily receive compliments from others
including their therapists, and tended to mini-
mize their needs and accomplishments in ther-
apy. Trust also was an obstacle in the therapeu-
tic relationship, and the need for approval from
therapists prevented them from being open and
disclosing. The study suggested that partici-
pants engaged in a meta-evaluative therapeutic
process in which they evaluated each other’s
connection and evaluation of the relationship as
they interacted. What participants found most
helpful, however, was feeling safe and under-
stood by their therapists, and therapist disclo-
sures about being invested in the therapeutic
relationship. Studies reviewed in this section
suggest that close attention to the psychother-
apy relationship is particularly important for
self-critical clients.
The Treatment of Self-Criticism Across
Approaches to Psychotherapy
Psychodynamic Therapies
Mechanisms of self-critical change.
Self-criticism has origins in psychoanalytic
frameworks and was developed within a psy-
choanalytic model of depression. For example,
Freud described self-criticism in the form of
moralistic superego attacks on the ego (Freud,
1917), and Justin Aronfreed (1964), a psycho-
analytic thinker, related self-criticism to inter-
nalized childhood experiences of punishment.
Object-relations scholars have a history of ex-
amining self-hatred through the lens of internal-
ized parent– child relationships (see Scharff &
Tsigounis, 2003).
Blatt’s (1974) work on trait-based subtypes
of depression was an important marker in de-
scribing individuals with self-critical personali-
ties. The first subtype of “anaclitic” or depen-
dent depression included interpersonal concerns
such as helplessness, fear of loss or abandon-
ment, and the need to be cared for, loved, and
protected. The second subtype of “introjective”
or self-critical depression was thought to be
characterized by feelings of inferiority, guilt,
and a sense of failure to live up to one’s expec-
tations and standards (Blatt et al., 1982). Blatt
and Zuroff (1992) described self-critical indi-
viduals as constantly striving for high achieve-
ment and perfection, and excessively concerned
about disapproval, and rejection from others.
Shahar (2001) discussed the role of shame in
introjective (self-critical) depression and sug-
gested that introjective individuals are sensitive
to perfectionistic messages that can be con-
veyed by their parents and by larger society.
The author goes on to state that perfectionistic
168 KANNAN AND LEVITT
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individuals may see achievement and striving
for perfection as a solution for their shame and
inadequacy, but in reality, the cycle of holding
unrealistic standards for oneself can, in fact,
exacerbate their lack of satisfaction with their
performance and lead to further self-degrada-
tion in the form of depression, eating disorders,
and even suicide.
Shahar (2004) has discussed ways in which
clients might deal with their self-criticism by
activating their therapists’ self-criticism or in-
adequacy. He described action theory as the
understanding that some interactional styles (e.
g., self-criticism) use behaviors (e.g., criticizing
others) that generate similar reactions in others
(e.g., introjected self-criticism) and create con-
ditions that, in turn, maintain their interaction
styles (e.g., rejection). Psychodynamic ap-
proaches therefore have been invaluable in not
only initially developing a focus on self-
criticism, but in the development of a contem-
porary theoretical and relational framework for
understanding self-criticism.
Treating self-criticism based on psychody-
namic theory: Critical voices and dialogical
narratives. A number of different approaches
to working with self-criticism have developed
from psychodynamic approaches. This focus is
evident in the work of Robert Firestone, a lead-
ing psychoanalytic theorist on self-destructive
processes and developer of the “voice therapy”
approach to treating self-criticism (Firestone,
1988). According to Firestone, change occurs
when the manner in which one processes self-
critical thoughts shifts (i.e., from an inwardly
directed process of negative ruminations, to an
external, free, and unrepressed voice). Drawing
on findings from research in attachment and
interpersonal neurobiology, voice-therapy tech-
niques are based on separation theory, which
integrates psychodynamic and existential per-
spectives in explaining how psychological de-
fenses formed very early in life are reinforced as
children develop an understanding of personal
mortality.
Voice therapy accesses clients’ core mal-
adaptive beliefs in the presence of emotional
arousal. The core therapeutic technique of voice
therapy is that clients learn to verbalize their
critical thoughts in the second person, as though
another person were talking to them. According
to this approach, shifting to this second person
format brings to the surface the emotional con-
tent of self-critical thoughts and allows for sep-
aration between the clients’ rationales and their
internalized self-critical attitudes. This process
allows the client to safely identify their sources
of self-criticism in painful childhood experi-
ences or trauma. This developmental perspec-
tive can lead to exploring which behaviors (e.g.,
addiction, anxiety) may be controlled or exac-
erbated by self-critical thoughts.
Layne, Porcerelli, and Shahar (2006) have
described Blatt’s depression subtypes and
called for combining psychodynamic and cog-
nitive approaches to working with self-critical
clients. In a client who demonstrated both
anaclitic and introjective forms of depression,
Layne et al. (2006) presented a case study of
a treatment for self-criticism that described
the client’s process of integrating positive
ideas into her self-concept over the course of
treatment.
Across these approaches, the function of hav-
ing clients recognize and verbalize negative and
internalized attitudes and their origins appears
to render them less powerful and permit a more
positive self-evaluation to be integrated. There
is a large volume of research on the effective-
ness of psychodynamic psychotherapies in gen-
eral (e.g., Jakobsen, Hansen, Simonsen, &
Gludd, 2012), and future research on use of
these specific therapeutic interventions to treat
self-criticism will continue to develop this field.
Cognitive Therapy
Mechanisms of self-critical change.
Cognitive therapy grew from Beck’s suspension
of psychoanalytic theory and behavioral theories
(Leahy, 2006) and creating a new framework that
outlined therapy procedures to change cognitions
(Beck, Rush, Shaw, & Emery, 1979;Rush, Beck,
Kovacs, & Hollon, 1977). Beck (1967) defined
cognitive schemas as “relatively stable cognitive
patterns” that are used consistently to interpret life
situations (p. 7). Young (1999) expanded on
Beck’s ideas and identified a set of 18 maladaptive
schemas, which have found some support in sub-
sequent research (Schmidt & Joiner, 2004). Some
of these early maladaptive schemas can promote
self-critical states, such as unrelenting standards,
hypercriticalness, and punitiveness. The change
mechanisms involved in cognitive therapy center
around understanding and changing dysfunctional
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or self-critical thoughts or schemas that individu-
als carry with them into different situations.
Treating self-criticism: Restructuring and
reattribution. Two commonly used examples
of interventions to treat self-criticism are mod-
ifying maladaptive schemas through cognitive
restructuring and reattribution (Beck et al.,
1979;DeRubeis et al., 1990). In the first inter-
vention, cognitions are restructured by identify-
ing and testing clients’ maladaptive schemas or
beliefs. Clients are taught to regard their self-
criticisms as hypothetical ideas that must be
tested in session. Beck employed Socratic ques-
tioning by asking clients questions to retrieve
information to challenge depressed thoughts.
For example, if a client says “I never do any-
thing right” the therapist might respond by ask-
ing the client to recall a recent accomplishment.
Cognitive restructuring may be practiced
through a variety of techniques such as role
playing, the use of imagery and reality testing to
promote a more adaptive and realistic self-view
(Beck et al., 1979). This conceptualization has
been reworked in Beck’s later work (1996)on
mode deactivation therapy (MDT), in which
schemas are not viewed as irrational, but as core
beliefs that serve a self-protective function. In
either case, once self-critical thoughts are iden-
tified, clients are encouraged to take on a more
objective approach in countering their self-
defeating thoughts.
The second intervention, reattribution, is
commonly used as a technique in working with
self-critical clients because of their tendency to
frequently hold themselves responsible for neg-
ative outcomes that are out of their control. The
goal here is to direct clients to assign the ap-
propriate amount of responsibility to them-
selves but also to external factors that may have
contributed to the clients’ difficulties. The ther-
apist also may choose to counter the clients’
cognitions by evaluating the “facts” or “truths”
about the event that resulted in self-criticism.
This technique also has been labeled “de-
responsibilitizing” (Beck et al., 1979).
Supporting research. There is a good deal
of evidence that cognitive approaches in general
are efficacious in treating disorders associated
with self-criticism, such as depression (e.g.,
Robinson, Berman, & Neimeyer, 1990). De Ol-
iveira et al. (2012) proposed a procedure for
cognitive restructuring, which focused on a
form of self-criticism called the trial-based
thought record (TBTR), and which was de-
signed to make patients aware of their self-
critical core beliefs. Patients in the study (N⫽
166) were submitted to a simulation of a legal
trial and their endorsements of negative core
beliefs and corresponding emotions were exam-
ined. Therapists (N⫽32) at different levels of
training in cognitive therapy and TBTR partic-
ipated in the study. Results indicated significant
reductions in patients’ adherence to core self-
critical beliefs as well as intensity in corre-
sponding emotions. Although the intervention
was conducted on just one session of psycho-
therapy, the present study also compared the
empty-chair approach to TBTR. No significant
differences were found between approaches,
and authors suggested that both methods seem
to work well, significantly reducing self-
criticism to a very low level.
Using a different approach, Gilbert et al.
(2004) analyzed self-critical individuals’ re-
sponses to failure from a schematic and cogni-
tive-interpersonal perspective (Baldwin, 1992;
Beck, 1967) via his compassionate mind train-
ing (CMT) approach. Their recent work (2006)
was based on the assumption that self-criticism
and self-reassurance are learned interpersonal
scripts (i.e., one relates to the self in ways others
have related to the self). They used a self-
imagery task with undergraduate students (N⫽
197) that examined the ease with which partic-
ipants could access and generate images related
to self-criticism and self-reassurance after an
imagined experience of failure. Self-criticism
was associated with ease and clarity in generat-
ing hostile self-images, while self-reassurance
was associated with ease in generating support-
ive self-images. They found that the power and
anger associated with the hostile images were
significantly related to self-criticism and de-
pression. Results also indicated that difficulties
in generating compassionate images could con-
tribute to feeling depressed. They suggested that
generating compassionate imagery can provide
a bridge between cognitive and emotional pro-
cesses in therapy, especially after a perceived
failure.
Emotion-Focused Therapy
Mechanisms of self-critical change.
Process-experiential theory (PE)/emotion-
focused therapy (EFT) is an empirically sup-
170 KANNAN AND LEVITT
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ported approach that integrates client-centered
and gestalt therapies, and is based within a
dialectical-constructivist philosophy. When po-
lar parts of the self are brought into contact with
each other, change can occur by developing an
awareness of the differences between these op-
posing parts. The goal in therapy is to help
clients arrive at a more integrated experience,
rather than maintaining a constant “split” be-
tween the two parts. The concepts and interven-
tions in this orientation were developed in the
1970s and the key proponents of this theory and
therapy were Leslie S. Greenberg, Laura N.
Rice, Sue Johnson, and Robert Elliott. Process-
experiential theory holds that emotions are es-
sentially adaptive for the regulation of behavior
and formation of attachment but become mal-
adaptive as a result of past traumas or learning
inappropriate styles of coping with and regulat-
ing painful emotions (Elliott, Watson, Gold-
man, & Greenberg, 2004). For example, some
self-critical clients may have developed the
maladaptive emotion of shame in response to
being belittled during their development. In this
orientation, distinctions have been made be-
tween primary and secondary emotional re-
sponses (Greenberg & Safran, 1987;Greenberg,
Rice, & Elliott, 1993). Primary emotions are
defined as “here-and-now, immediate, direct re-
sponses to situations,” such as sadness in rela-
tion to loss, or fear in response to threat (Green-
berg et al., 1993, p.75). Secondary emotions are
more reactive in nature and obstruct the primary
emotion process, such as expressing anger in
response to underlying fear or sadness.
Therapeutic change also can be produced
through activating “emotional schemes,” de-
scribed as “nonconscious mental structures”
(Greenberg et al., 1993, p. 66) that can deter-
mine how individuals experience and perceive
themselves in relation to the world. They are
different from cognitive schemas in that they
are largely affective and nonverbal modes of
experiencing (Greenberg, Watson, & Goldman,
1998). According to Greenberg and Paivio
(1997), these emotion schemes are automati-
cally produced and can be based on past emo-
tional experiences or emotion-based memories
developed from birth (e.g., immediate anger at
feeling violated or fearful when faced with
threat). These emotion schemes can generate
dysfunctional responses in clients, especially
when schemes activate damaging or traumatic
aspects of experience. This model holds that
emotions themselves are not maladaptive. In-
stead, the anxiety or depression that develops
from anticipation that a certain need will not be
met or that particular emotions should be
avoided, can lead to maladaptive coping. The
negative affect or feeling (such as contempt or
disgust for the self) that accompanies an indi-
vidual’s self-criticism is considered to be the
main factor in maintaining self-critical beliefs
in this model.
Treating self-criticism in EFT: The two-
chair dialogue. The main intervention used to
treat self-criticism within the EFT model is the
two-chair dialogue exercise that is designed to
respond to self-criticism or a self-critical split.
The task of the therapist is to structure a dia-
logue between the self-critical aspects of the
client, or the self-critic, and the part that is being
criticized, referred to as the self (Greenberg et
al., 1993, p. 189). The intervention typically is
engaged in response to clients’ verbal state-
ments or markers of self-criticism in the course
of a session such as “I’m a failure” or “I should
work harder” (Greenberg et al., p. 189).
The resolution of self-criticism occurs in
three main stages (Greenberg et al., 1993,p.
198). First, opposition: Once a marker that is,
the self-critical split has been identified, the
therapist helps clarify what the two opposing
sides of the conflict are. Here, the therapist’s
goal is to heighten each side of the conflict by
directing the critic to verbalize specific criti-
cisms (e.g., “You are a coward,” verses a global
statement such as “You are bad”) and directing
the self to describe their impact and/or protest.
With this verbalization, clients can recognize
the intensity and harshness with which they
evaluate themselves. Second, in the next stage
of contact, the crux of the work involves engag-
ing the client’s emotions on both sides of the
split. The therapist encourages the client to stay
with and elaborate on difficult feelings, rather
than move away from them. This differentiation
of feelings generates new meaning-making as
well as identifying new needs that emerge from
the differentiated feelings (e.g., I need to seek
support when I feel frightened and vulnerable).
The third and final stage of integration occurs
when the critic and the self have expressed their
feelings and associated needs, and the critic
begins to soften or become more self-soothing,
and less evaluative, harsh, or blaming. The ini-
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tial blaming critic voice may be replaced by
concern or fear (e.g., the critic’s initial harsh
statement toward the self of “You are a failure”
may soften to “I am scared that I will be hurt if
I fail”). A process of negotiation of needs and
wants takes place between the two sides in this
manner, until a more unified perspective is
reached between the self and the critic. Notably,
the goal of treatment is not to eliminate self-
criticism, as self-criticism can have adaptive
aspects that clients wish to maintain, but to help
clients develop a resolution that is useful for
them.
Supporting research. Research on experi-
ential therapies generally has shown positive
changes in clients’ emotional states and therapy
outcome (Adams & Greenberg, 1996;Korman,
1998;Greenberg, Elliott, Watson, & Bohart,
2001;Elliott, Greenberg, & Lietaer, 2004). For
example, Elliott, Greenberg et al. (2004) meta-
analysis reported large effect sizes for process-
experiential therapy, including a pre–post effect
size of 1.26 (N⫽18 studies), which indicated
that the average treated client in those studies
had positively moved one and a quarter standard
deviations during therapy. Additionally, 46
studies comparing cognitive– behavioral thera-
pies to experiential therapies were found to be
clinically equivalent (Elliott, Greenberg et al.
2004).
Ben Shahar et al. (2012) conducted a one-
session pilot study to investigate the efficacy of
a two-chair self-critical split task on self-
criticism, self-compassion, and the ability to
self-reassure in times of stress, as well as on
depressive and anxiety symptoms among highly
self-critical clients (N⫽9). Results indicated
that the intervention was associated with signif-
icant increases in self-compassion and self-
reassuring behaviors, and significant reductions
in self-criticism, depressive symptoms and anx-
iety symptoms, as evidenced by moderate to
large effect sizes. These studies, although pre-
liminary, have implications for Paul Gilbert’s
(2000) conceptualization of self-criticism where
in his view, constant practice or training clients
in self-compassion is necessary in defending
oneself against self-criticism because self-
soothing has been an underdeveloped practice
in self-critical clients (Gilbert & Irons, 2005).
Like Ben Shahar et al. (2012);Whelton and
Greenberg (2005) examined the immediate
emotional effects of self-criticism among psy-
chology undergraduates in a large metropolitan
university in Canada by using a one-session
intervention (N⫽60). Participants were di-
vided into three groups whose self-ratings on
the Depressive Experiences Questionnaire
(DEQ) indicated high self-criticism (n⫽30),
high dependency (n⫽15), and the third group
combined both low dependency and low self-
criticism scores (n⫽15). They were asked to
recall an experience of failure (to induce a dys-
phoric mood), and then criticize themselves and
respond to their criticisms via an empty-chair
technique. The high self-critics were judged as
being significantly more contemptuous than the
controls in their self-criticisms and also were
less resilient to their criticisms. Also, they ex-
perienced more sadness and shame in response
to the criticisms and had difficulties with ver-
balizing confident or assertive responses to their
self-critics.
These findings relate to Kelly, Zuroff, and
Shapira’s (2008) research on self-criticism, self-
compassion, and resisting self-critical attacks.
They found that experiences of shame were
highly prevalent among self-critics in a non-
clinical sample (N⫽75). They developed two
self-help interventions based on Gilbert and
Irons’ (2005) compassionate mind training ap-
proach, and incorporated chair work from Ge-
stalt and emotion-focused therapies (Greenberg
et al., 1990;Perls et al., 1951). Participants were
randomly assigned to (a) a control condition, (b)
a self-soothing intervention that invited partici-
pants to engage in compassionate, nurturing,
and reassuring imagery and self-talk, and (c) an
attack-resisting intervention that asked partici-
pants to engage in strong, resilient, and retali-
ating imagery and self-talk. They found that
over a 2-week period, the attack-resisting con-
dition lowered ratings of depression signifi-
cantly more than the control condition, as well
as lowered ratings more for high than for low
self-critics. Individuals in both intervention
groups showed greater and significant reduc-
tions in shame experiences than controls across
time.
In addition, other researchers who have stud-
ied emotional processes (Leary, Tate, Adams,
Allen, & Hancock, 2007) found that self-
compassion was negatively related to negative
emotion, specifically, anxiety, sadness, and self-
conscious emotions, such as embarrassment or
guilt. These results suggested the importance of
172 KANNAN AND LEVITT
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helping clients develop empathy and self-
compassion (Chang, 2008;Gilbert & Irons,
2005;Whelton & Greenberg, 2005), as well as
build emotional assertiveness or resilience
(Greenberg et al., 1998) against the harsh and
controlling aspects of the self-critic. The find-
ings in this section speak to the growing impor-
tance of addressing self-criticism across treat-
ment modalities. Interventions across therapy
orientations tend to address self-criticism
through multiple methods, such as building em-
pathy and self-compassion, shifting intensity of
core beliefs, evoking primary emotion, and re-
scripting self-critical beliefs.
Integrating Understandings of
Self-Criticism
Through this review, the following principles
have been identified as common across treat-
ments for self-criticism. These might serve as
useful foundations for an understanding of com-
mon factors or processes that address self-
criticisms or for the development of integrative
treatments for self-critical clients. As self-
criticism has been associated with negative out-
comes in the psychotherapy literature reviewed
(e.g., Marshall, Zuroff, McBride, & Bagby,
2008;Rector et al., 2000), it is important to
consider ways to deal with self-criticism when it
emerges in therapy.
Self-criticism can be a harmful force in
clients’ lives. Excessive self-criticism has
been viewed as harmful across orientations, de-
spite its adaptive aspects. It is prominently sit-
uated as an important predictor of depression
within theoretical models of depression that
have discussed the role of self-criticism (Beck
et al., 1979;Greenberg, Watson, & Goldman,
1998;Shahar, 2001). It is unclear how self-
criticism would be conceptualized in other cli-
ent pathology or nonclinical populations, al-
though some research (Luyten et al., 2007;
Whelton & Henkleman, 2002) has suggested
that self-criticism can be harmful even within
normal populations.
Client self-criticism is maintained due to a
subconscious maladaptive coping response.
Self-criticism is maintained when clients prac-
tice automatic and maladaptive ways of reacting
to and coping with self-criticism. For example,
in cognitive therapy, certain dysfunctional
thought patterns such as brooding or overgen-
eralization of failures were thought to carry
forward one’s self-critical and depressive think-
ing (Beck et al., 1979;O’Connor & Noyce,
2008;Miranda & Nolen-Hoeksema, 2007). In
EFT, clients maintained their self-criticisms by
inappropriately regulating the emotions related
to them and using secondary emotional process-
ing or avoidance. For example, a client who
fears intimacy may react with anger in response
to her partner’s attempts at affection. Psychody-
namics conceptualize self-criticism as main-
tained through internalized relationships
(Scharff & Tsigounis, 2003), disruptions of per-
sonal relationships (i.e., object loss, Shahar,
2001), or maladaptive defense mechanisms.
These psychotherapy orientations all share a
sense that self-criticism becomes automated and
may need to be drawn into awareness before its
full extent can be recognized by clients.
Interventions centered on awareness of
both the content and process of self-criticism.
Clients’ awareness about self-criticism was
regarded as an important focus for the three
orientations (i.e., cognitive, psychodynamic,
and emotion-focused therapies). Promoting
awareness might take different forms in each
orientation (such as disputing self-critical
thoughts, exploring transference, or chair-work)
and eliciting clients’ self-criticisms was impor-
tant so that therapists and clients could better
understand the problematic ways in which cli-
ents were relating to themselves. This goal fur-
thered the therapeutic relationship, in which
therapists could connect with clients’ harsh
views of themselves, and use the alliance as a
tool to teach adaptive ways of relating to the
self. Across these approaches, the clients be-
came aware not only of the specific self-
criticisms that they harbored, but also the pro-
cesses and roots of self-criticism. This aware-
ness generated the possibility for changing both
the content and the nature of self-criticism.
Resolving self-criticism by strengthening
the self (not eradicating self-criticism).
Across the orientations explored, self-criticism
was resolved by changing the manner in which
it was being understood and processed by cli-
ents. For example, a strength of cognitive ther-
apy is to teach clients ways in which they could
displace their self-criticisms by being assertive
and assigning blame to external rather than in-
ternal factors. Psychodynamic approaches can
act to help clients become aware of unconscious
173CLIENT SELF-CRITICISM
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self-criticism so they can integrate more posi-
tive understandings of themselves (e.g., Layne,
Porcerelli, & Shahar, 2006). In EFT, clients’
chairing often shapes a kinder, self-protective
critic that could be useful to their growth rather
than harmful, and a stronger, more confident
self (e.g., Greenberg, Rice, & Elliott, 1993).
Although the three orientations moved their cli-
ents away from the damaging and self-destruc-
tive to more constructive and less harsh per-
spectives of self-criticism, this did not mean
eliminating all self-criticism, but rather keeping
healthier forms of self-criticism and maintain-
ing adaptive responses to self-criticism.
Resolution of self-criticism: Externalizing
the self-position. The treatment findings and
theoretical literature suggested that therapists
guided clients toward modifying their position
in relation to their self-critic or self-criticism
(e.g., from a self-destructive to a self-protective
critic in EFT, from an internal to an external
voice in psychodynamic therapy, or from an
internalized self-blame position to a more ex-
ternalized stance in cognitive therapy). In the
review of the intervention literature, the orien-
tations engaged clients in this process of explic-
itly exploring their self-critical thoughts and
emotions (e.g., through guided discovery in
cognitive therapy, the exploration of the critical
voice in psychodynamic therapy, and the self-
critical two-chair dialogue interventions in
EFT). Through this outwardly exploratory pro-
cess, clients may begin to feel more empowered
to effectively deal with their criticisms.
The demonstration of empathy and
compassion. In the studies on alliance, clients
with high levels of self-criticism and perfection-
ism that were found in early and later stages of
treatment tended to have alliance difficulties in
therapy Whelton et al., 2007;Zuroff et al.,
2000). In addition, clients reported that negative
emotions of fear and shame prevented them
from disclosing what they were distressed about
in therapy (Janzen, 2007). With these findings,
researchers suggested that establishing and
maintaining empathetic bonds with the client
can be important in gaining clients’ trust as well
as creating an environment of safety for client
disclosure. Empathy can provide a direct learn-
ing or “corrective relational experience” to cli-
ents (Greenberg et al., 2001, p. 382), and the
alliance between client and therapist may help
strengthen the self. Using EFT, empathy as an
intervention can be validating and reassuring to
self-critical clients, especially when clients
struggle with intense negative emotions (e.g.,
shame). In cognitive therapy, empathy serves to
further treatment goals and to understand cli-
ents’ core beliefs and thought patterns. Meta-
communication with clients about their self-
critical processes in therapy can help gauge how
clients perceive themselves and the therapist, as
well as better understand their needs in therapy
(e.g., asking clients how they may be holding
back issues in therapy for fear of failure, shame,
and disappointment). In psychodynamic ap-
proaches, exploring transference patterns could
help clients understand how their self-criticism
functions in the context of their relationships.
Enhancing client agency through increasing
clients’ self-compassion and assertiveness. In
this review, the three orientations tried to en-
hance clients’ sense of agency to deal with
self-criticism in their lives. They attempted to
extend and restructure the ways in which clients
typically related to themselves (e.g., from self-
attacking to self-nurturing or self-enhancing).
This conceptualization is apt, given that the
findings across the psychopathology and psy-
chotherapy literature on self-criticism, which
suggest that self-critical clients tend to experi-
ence a sense of defeat, inferiority, and self-
blame around stress, failure, and negative emo-
tion (Dunkley et al., 2006;Flett, Hewett, Blank-
stein, & Gray, 1998). In EFT, therapists dealt
with this failed self by helping clients adopt a
more compassionate view of themselves and
their perceived failures and stresses (e.g., via
softening the critic). In cognitive therapy, the
focus was on harnessing clients’ sense of asser-
tiveness (e.g., via disputing cognitions or in-
creasing assertiveness by not giving into rumi-
native cognitive styles). In psychodynamic ap-
proaches, therapists helped clients build up self-
esteem (e.g., by drawing their attention to their
strengths and accomplishments).
Preparing therapists to tolerate criticism.
In this review, the literature suggested that cli-
ents with high levels of self-criticism predicted
a poorer response to psychotherapy, feelings of
contempt when they did not meet their high and
unattainable standards, and were resistant to
acknowledging treatment successes (Gilbert et
al., 2006;Janzen, 2007;Rector et al., 2000).
As a result, therapists may need to develop
processes to deal with their own self-criticisms.
174 KANNAN AND LEVITT
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Therapists’ abilities and comfort levels in deal-
ing with client self-criticism may be, in part, a
function of their own self-critical attitudes, be-
liefs, and experiences (Shahar, 2001;Vane,
2004). In addition, tolerating, accepting, and
connecting with difficult and intense negative
emotions from self-critical clients also can be a
fruitful area of exploration for therapists
(Greenberg, Rice, & Elliot, 1993). And explor-
ing countertransferential reactions could pro-
vide therapists the opportunity to recognize and
manage such responses. Given these intra- and
interpersonal difficulties, therapists also might
benefit from exploring clients’ concerns at the
start of therapy, as well as addressing clients’
unrealistic expectations of success.
A Brief Conclusion
Suggestions for future research to improve
the breadth and depth of research in this area
include: (a) Research on how self-criticism re-
lates to psychological phenomena other than
depression, perhaps in diagnostic categories
such as anxiety, substance abuse, and self-
image issues; (b) study of the adaptive functions
of self-criticism and the processes involved in
less severe self-criticism; (c) the development
of operational and distinct definitions of self-
criticism that are distinct from depression and
perfectionism, perhaps based upon factor-
analytic research; (d) research on cultural fac-
tors and self-criticism to enrich our understand-
ing of the scope of self-criticism—for instance,
explicitly communicated self-criticism (i.e.,
self-critical attitudes directly expressed to fam-
ily and friends) may serve the purpose of re-
ceiving others’ care, compassion and support in
Japanese culture (Kitayama & Markus, 2000).
And given the link between depression and gen-
der, it may help to study self-critical processes
in women (Luyten et al., 2006;Wu and An-
thony, 2000). (e) Future research also could
continue to advance the revival of psychody-
namic approaches to the treatment of self-
criticism and integrate the different approaches
to working with self-criticism.
This paper has identified commonalities that
might act as core principles for treatment across
psychotherapy approaches or integrations, with
a focus on self-criticism. Self-criticism ap-
peared to be experienced with intense negative
affect, as well as disturbing and ruminative
thoughts related to the self, both of which can
be daunting for therapists to confront. This un-
derstanding can provide direction for continued
research and can provide graduate therapists in
training treatment guidelines for how to best
treat self-critical clients in psychotherapy.
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Received October 10, 2011
Revision received January 15, 2013
Accepted January 28, 2013 䡲
178 KANNAN AND LEVITT
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