HEALING SHAME IN SUBSTANCE USE RECOVERY Healing Shame in Substance Use Recovery through Art Therapy Jamie Schoen Department of Psychology, Counseling, and Art Therapy, Pennsylvania Western University COUN 7560: Art Therapy Research Dr. Sheila Lorenzo de la Peña 1 HEALING SHAME IN SUBSTANCE USE RECOVERY 2 Abstract Shame plays a major role in the lives of individuals with substance use disorders (SUDs) and can affect how they see themselves, how they connect with others, and how they navigate through recovery. Many individuals with SUDs struggle with stigma, past trauma, and low selfworth. This can make it hard to be hopeful, stay engaged in treatment, or believe they can change. Addressing shame is an important part of helping individuals rebuild their identity and strengthen their emotional well-being. This paper explores how shame impacts individuals with SUDs and introduces an 8-week art therapy curriculum (see Appendix A) created for adults in inpatient treatment. The curriculum combines ideas from the Trauma, Addiction, Mental Health, and Recovery model (TAMAR), Dialectical Behavior Therapy (DBT), Compassion-Focused Therapy (CFT), and Art Therapy to help clients understand their emotions, build selfcompassion, and explore their creative expression. Through creating art, clients have a creative and meaningful way to explore their experiences, reduce shame, and develop skills that will support their lifelong recovery. HEALING SHAME IN SUBSTANCE USE RECOVERY 3 Section I: Introduction Substance use disorders (SUDs) affect many areas in an individual's life, including their relationships, emotions, and sense of self. Recovery is not only about stopping substance use but also about understanding the feelings and experiences that come with it. These include shame, rebuilding identity, self-worth, and finding a sense of belonging. Many individuals with SUDs have feelings of shame, which may be related to their past trauma, stigma, or the use itself. This shame can deeply affect how an individual views themself and their personal growth. Shame can lead to withdrawal, isolation, and disconnection from others. It can also make it difficult for individuals to feel like they deserve support or feel confident in their progression through recovery. Addressing shame is essential for those with SUDs. Art therapy offers a way for individuals to express and explore these feelings in a safe and creative way while also learning new coping skills, emotional regulation skills, and a stronger sense of self. Through creative expression and reflection, individuals can start to look at themselves with more compassion and openness, which supports their recovery process. This leads to exploring how shame influences the recovery process and why it should be addressed in treatment. Problem to be Investigated Shame plays a significant role in SUDs and contributes to ongoing use, isolation from others, and barriers to recovery. Shame has a negative impact on identity, self-esteem, and a person's sense of belonging. Those with SUDs experience shame that can be increased by stigma, past trauma, or co-occurring disorders. These factors can make it difficult to seek help, remain engaged in treatment and recovery, or have hope for change. Purpose Statement HEALING SHAME IN SUBSTANCE USE RECOVERY 4 The purpose of this research is to explore how shame affects adults in substance use recovery and to develop an art therapy curriculum that helps reduce shame, rebuild identity, develop self-compassion, and support emotional stability throughout the recovery process (see Appendix A). Justification SUDs are one of the most significant mental health challenges in the United States that affect millions of people. The National Survey on Drug Use and Health in 2024 reported that 48.4 million people (16.8%) aged 12 or older had an SUD in the past year (SAMHSA, 2025). These results indicated that 27.9 million (9.7%) individuals had an alcohol use disorder and 28.2 million (9.8%) individuals had a drug use disorder (SAMHSA, 2025). These numbers highlight how many individuals in the country are struggling with substance-related problems and the need for effective treatment approaches. SUDs are one of the most serious behavioral issues worldwide and are often connected to high relapse rates, co-occurring mental health issues, and premature mortality (Degenhardt, 2018). Research shows that more than 85% of individuals relapse within one year of treatment (Sinha, 2011). Many of these individuals also struggle with shame and stigma, which can make recovery even more difficult. SUDs are a major concern and contribute to serious emotional, psychological, and physical consequences. Those with SUDs often experience stigma, shame, and judgment, which makes recovery more difficult. Various studies show that shame is one of the biggest barriers to recovery that can lead to higher rates of relapse and withdrawal (Batchelder et al., 2022; Snoek et al., 2021). Shame can lead to recurring patterns of harmful behaviors such as continued use, selfblame, self-hate, and feelings of worthlessness, which all affect an individual's self-esteem and identity. Along with shame, many people with SUDs also have a history of trauma, which HEALING SHAME IN SUBSTANCE USE RECOVERY 5 increases their emotional distress and creates challenges in the recovery process. These factors show why shame should be addressed and not overlooked in treatment, as it plays a major role in the recovery process and possible relapse. Terms Related to the Study Compassion-Focused Therapy: A therapeutic approach that helps individuals understand and work with their suffering in compassionate, non-shaming ways (Kolts, 2016; Gilbert, 2010). Dialectical Behavior Therapy: A therapeutic approach based on dialectical and biosocial theory of psychological disorders that focuses on mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness (Linehan, 2014). Recovery: “A process of change through in which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential” (SAMHSA, 2012). Self-Esteem: The evaluation of one's worth, including how much a person likes and believes in themselves (Zeigler-Hill, 2013). Shame: “The painful emotion arising from the consciousness of something dishonoring, ridiculous, or indecorous in one’s own conduct or circumstances (or in those of others whose honor or disgrace one regards as one’s own), or of being in a situation , which offends one's sense of modesty and decency” (Oxford English Dictionary, n.d., p. 3). Stigma: A social process where negative stereotypes, judgments, and labels are placed on individuals, which leads to discrimination, social rejection, and internalized shame. Substances: Chemical substances that alter an individual's mood, cognition, behavior, or physical functioning (e.g., alcohol, prescription medications, and illegal drugs). HEALING SHAME IN SUBSTANCE USE RECOVERY 6 Substance Use Disorder (SUD): “A cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems” (American Psychiatric Association, 2022, p. 483). Trauma: A distressing experience or event that leaves a lasting emotional or psychological effect on an individual. Conclusion Shame plays a significant role in the lives of those with SUDs and how it shapes the way they see themselves, their emotional well-being, and their journey through recovery. Shame creates barriers that make it hard to seek help, stay engaged, and maintain a sense of hope. It is important for SUD treatment to address shame and help individuals rebuild their identity, confidence, and coping skills. This work introduces an art therapy curriculum designed to reduce shame and support individuals in their healing process (see Appendix A). HEALING SHAME IN SUBSTANCE USE RECOVERY 7 Section II: Review of Literature Substance use disorders (SUDs) are widespread and can have significant emotional, psychological, and social effects on individuals. Among these challenges is shame, which plays a major role in shaping how individuals see themselves, how they relate to others, and how they participate in recovery. Shame can contribute to an individual's cycle of avoidance, isolation, and continued substance use, which can affect whether they seek help or if they believe they are worthy of change. This paper explores therapeutic approaches that address both substance use and the role of shame, including the Trauma, Addiction, Mental Health, and Recovery model (TAMAR), Dialectical Behavior Therapy (DBT), Compassion-Focused Therapy (CFT), and the incorporation of art therapy. Understanding the impact of shame in SUDs can help guide recovery toward compassion, belonging, and restoring a more stable sense of identity. Substance Use and Substance Use Disorder SUDs are defined as a pattern of cognitive, behavioral, and physiological symptoms that indicate an individual continues using a substance even though it causes significant problems in their life (American Psychiatric Association, 2022). Over time, the classification of SUD has changed throughout the different editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM). SUDs began as a subcategory of Personality Disorders and Other Nonpsychotic Mental Disorders in the DSM-I but are now a separate category of SubstanceRelated and Addictive Behaviors in the DSM-5-TR (Douaihy & Daley, 2014). Within the Substance-Related Disorders section, there are “10 separate classes of drugs, including alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics or anxiolytics, stimulants (amphetamine-type substances, cocaine, and other stimulants), tobacco, and other or unknown substances” (American Psychiatric Association, 2022, p. 1120). SUDs encompass a HEALING SHAME IN SUBSTANCE USE RECOVERY 8 wide range of substances and can have significant negative effects on an individual's life. Understanding the prevalence and patterns of SUDs among adults is key to recognizing the significant effects these disorders have on mental health and treatment needs. Adults who use Substances There are three nationally representative surveys that conduct research on substance use prevalence in U.S. adults. These include the National Comorbidity Survey Replication (NCS-R), the National Epidemiological Survey on Alcohol and Related Conditions (NESARC), and the National Survey on Drug Use and Health (NSDUH) (Douaihy & Daley, 2014). It’s important to distinguish that there is a difference between substance abuse, which involves harmful use, and substance dependence, which is a more severe pattern that includes compulsive use and psychological effects that develop over an extended period. In a NESARC study, the lifetime prevalence of alcohol abuse was 17.8%, and alcohol dependence was 12.5% (Douaihy & Daley, 2014). In comparison, the NCS-R study reported lifetime rates of 13.2% for alcohol abuse and 5.4% for alcohol dependence (Douaihy & Daley, 2014). Even though the rates are different between the studies, both show that alcohol use disorders are widespread and that a significant portion of the population experiences severe use. For drug use disorders, both studies reported estimates from 2% to 3% (Douaihy & Daley, 2014). This indicates that even though drug use is less common than alcohol disorders, it still impacts millions of individuals. These prevalence rates show that SUDs are not rare; instead, they affect a substantial portion of the U.S. population. Gender is an important characteristic that influences human behavior and has been studied to determine whether it plays a role in substance abuse and addiction. According to Cotto et al. (2010), males (sex assigned at birth) tend to be at a higher risk for substance use problems HEALING SHAME IN SUBSTANCE USE RECOVERY 9 than women. In 2008, males aged 12 or older accounted for nearly 60% of the estimated 20 million individuals who reported past-month illicit drug use (Cotto et al., 2010). In a study using data from NDSUH, males aged 18-25 years had higher rates of drug abuse for most substances, except for cocaine, where females showed higher rates (Cotto et al., 2010). These findings show that men and women experience substance use differently, which could explain why men more often meet abuse criteria and women are more dependent. Abuse criteria include behaviors like legal trouble, work or school problems, or reckless behaviors, while dependency criteria include tolerance, withdrawal, and difficulty stopping. Men are more likely to use substances in ways that are tied to externalizing behaviors like acting out or risk-taking, while women are more likely to use substances to cope with internalizing behaviors like anxiety or depression (Cotto et al., 2010). It’s also important to recognize that these differences may be shaped by an individual’s culture and the environments that they grow up in, which ultimately influence how emotions are expressed, how help is sought, and how substance use is seen. When it comes to understanding SUDs, it’s important to think about the individual's culture and ethnicity and what role it may play within their thought processes, treatment, and recovery. The Center for Behavioral Health Statistics and Quality (2021) reports data from the 2015 to 2019 National Survey on Drug Use and Health (NSDUH), where 68,000 individuals aged 12 and older were surveyed annually. The results found that American Indian/Alaska Native individuals showed higher rates of SUDs, with 11.2%, followed by individuals identifying with two or more races (10.4%), white individuals (7.8%), Black and Hispanic individuals (7.1%), and Asian individuals (4.1%) (Center for Behavioral Health Statistics and Quality, 2021). These results bring up and highlight how historical and cultural aspects and community stressors might shape substance use and dependency. Another comparable study, HEALING SHAME IN SUBSTANCE USE RECOVERY 10 Acevedo et al. (2012), studied treatment initiation and treatment engagement within 4,927 racially/ethnically diverse adults who were receiving outpatient treatment. The study found that Black individuals were less likely to initiate treatment compared to White and Native American individuals and that race/ethnicity did not play a part in treatment engagement (Acevedo et al., 2012). The findings suggest that cultural experiences, access barriers, and experiences of trust or mistrust in mental health systems may influence when an individual feels able to start treatment. Culture and ethnicity can play a part in both the development and continuation of substance use disorders and coincide with barriers to getting care, such as stigma, discrimination, and limited cultural services. Along with looking at social and environmental impacts, it's necessary to also look at biological factors, such as the brain and coping behaviors. Understanding the Problem Understanding SUDs and the challenges they pose for an individual starts with understanding the neurobiological aspects. At its core, addiction is a neurobiological illness where chronic substance use dysregulates the brain's system of rewarding and adaptive behaviors, leading to substance-driven neuroplasticity, which is the nervous system’s ability to adapt both structurally and functionally (Douaihy & Daley, 2014). Three major areas in the brain are involved in biologically rewarding behaviors: the nucleus accumbens , which regulates reward-related behaviors; the amygdala , which mediates threat responses; and the prefrontal cortex , which supports decision-making and the anticipation of rewards by evaluating the significance of environmental stimuli (Kalivas & Volkow, 2005). All drugs that have addictive features enhance mesolimbic dopaminergic (DA), which is a reward synaptic function in the nucleus accumbens (Douaihy & Daley, 2014). While DA is the main component in initiating drug reinforcement, there are other neurotransmitters that indirectly impact the reinforcing HEALING SHAME IN SUBSTANCE USE RECOVERY 11 effects of addictive substances, including gamma-aminobutyric acids, opioid peptides, glutamate, serotonin, acetylcholine, and endocannabinoids (Douaihy & Daley, 2014). Substance use often starts casually as occasional or recreational use to then as impulsive use, and eventually to habitual, compulsive drug-seeking behavior (Douaihy & Daley, 2014). This corresponds with a shift from reward-driven to habit-driven behavior. Along with the dysregulation of the brain’s reward system, the condition of neuroplasticity is often reflected in compulsive drug-seeking behavior (Douaihy & Daley, 2014). Addiction does not stop after the last use of the drug; it often continues for years as the abused drugs elicit a dopamine response that exceeds that of natural rewards. Natural rewards are behaviors that trigger dopamine, also known as the “feel-good” transmitter, such as food, water, social connections, physical exercise, and sex or physical intimacy. Unlike with natural rewards, this response intensifies with repeated exposure rather than diminishing. This becomes a sense of “overlearning” where the drug-seeking behavior contributes to the initiation and maintenance of the addiction cycle, which explains the heightened susceptibility to craving and relapse (Kalivas, 2007). Genetic susceptibility, environmental influences, and alterations in the brain’s reward and stress systems all increase the risk of developing dependence and relapse in addiction (Douaihy & Daley, 2014). Biological factors like genetic vulnerability are a significant aspect of addiction. According to (Goldman et al., 2005; Hiroi &Agatsuma, 2005), approximately 40% to 60% of developing a substance use disorder can be attributed to genetic heritability. Sociocultural and familial systems can influence the development of SUDs, their maintenance, and their treatment. Substance use disorders are influenced by contextual factors, which can be seen through Urie Bronfenbrenner’s (1979) development of the social ecological model (Douaihy & Daley, 2014). HEALING SHAME IN SUBSTANCE USE RECOVERY 12 This model shows how human development is influenced by external factors in both the social and cultural world (Douaihy & Daley, 2014). It’s divided into four parts, called the contexts or environments , which include: macro-systems, including global factors like ethnic heritage and religious ideologies, exo-systems , which encompass community influences, such as urban vs rural living, meso-systems that reflect specific group influences, such as schools or religious institutions, and micro-systems , which consist of family, friends, and other peers (Douaihy & Daley, 2014). These social and cultural aspects impact not only the development and maintenance of SUDs but also contribute to the formation of stigmas, which create a barrier to treatment, recovery, and relapse. Stigmas Related to SUDs Individuals with substance use disorders experience a range of negative consequences due to their use, including the social challenge of stigmatization (Crapanzano et al., 2018). Stigmatization is a process in which members of a society collectively assign stereotypes to a specific group of people, often resulting in discrimination towards those who do not conform to social norms (Crapanzano et al., 2018). There are two different types of stigmas: public stigma, which is the impact of others within a community, and the negative stereotypes they create while self-stigma is what people do to themselves internally (Corrigan et al., 2009a). Stigma related to addiction is linked to harmful effects, as it can reinforce continued use and create barriers to access treatment. Many individuals with SUDs internalize these societal stigmas, which can lead to diminished self-respect, lower self-esteem, and reduced self-efficacy (Crapanzano et al., 2018). Crapanzano et al. (2018) conducted a narrative review exploring how perceived social stigma and self-stigma can affect the recovery process in individuals undergoing treatment for SUDs. Findings from qualitative studies found that stigma surrounding SUDs negatively HEALING SHAME IN SUBSTANCE USE RECOVERY 13 influence the individuals’ beliefs, attitudes, and emotions around treatment, often resulting in feelings of shame, guilt, and fear of judgment (Crapanzano et al., 2018). The quantitative results produced mixed results, with some showing direct links between stigma and poorer outcomes while others found weaker or non-significant correlations (Crapanzano et al., 2018). Similarly, Corrigan et al. (2009a) had 815 participants read a vignette about a person who was suffering from either a mental illness, drug addiction, or physically handicapped in a wheelchair, then answer questions revolving around attribution and judgments. Findings indicated that those with psychiatric disabilities were viewed more negatively, were deemed more dangerous, and evoked more fear than those with physical disabilities (Corrigan et al., 2009a). These patterns highlight that stigma around addiction is shaped by both others and how individuals with SUDs view themselves. Stigma surrounding addiction also extends into the process of seeking help and entering treatment. Stigma is a huge barrier for individuals seeking help or seeking treatment for SUDs. According to Barry et al. (2014), Americans hold significantly more negative attitudes towards those with drug addictions than those with mental health disorders, which negatively affects assessing treatment. In addition to how people with SUDs see themselves and are viewed by others, stigma also shows up on a structural level. Widely held negative beliefs indirectly lead to less support for policies that would expand health insurance coverage and increase funding for treatment services (Barry et al., 2014). Just as public stigma can affect an individual's decision to seek help, their own self-stigma can also prevent them from pursuing their recovery. Corrigan et al. (2009b) describe the “Why Try” effect, which explains how individuals who internalize stigma about their substance use begin to believe negative stereotypes about themselves and view themselves as weak, failed, worthless, and incapable. This mentality can prevent people HEALING SHAME IN SUBSTANCE USE RECOVERY 14 from pursuing treatment or their recovery goals. One proposed way to combat this is with empowerment (peer support, community, shared identity) that focuses on rejecting negative stereotypes and helping maintain the individual's ability to pursue their personal goals (Corrigan et al., 2009b). Stigma operates both externally and internally, both of which impact a person's emotional well-being, sense of identity, and motivation for recovery. For that reason, it is important to consider the psychological and emotional impacts of SUDs. Psychological and Emotional Impacts of SUDs Those with substance use disorders tend to experience many similar emotional and psychological impacts. These disorders can influence an individual's self-worth, trigger feelings of shame and guilt, diminish their identity and self-esteem, and often coexist with other mental health struggles. According to Pickard (2020), individuals may continue using substances even though they are harmful because the behavior holds a sense of meaning or value to them. These individuals generally suffer with purpose, structure, self-esteem, and their sense of self and social identity, so they turn to self-identifying as just an “addict” to fill that void. An individual with SUDs may see quitting or seeking help as losing their community, routine, self-worth, and their answer to “who am I?” (Pickard, 2020). It can make recovery feel like stepping into emptiness, which may bring up more shame and a fear of not knowing who they are (Pickard, 2020). Healing involves more than sobriety; it involves figuring out who you are, identifying feelings of shame, repairing identity, and building a stable sense of self. Shame The concept of shame is difficult to define, as it encompasses multiple interpretations depending on the individual. According to the Oxford English Dictionary (n.d.), shame is: HEALING SHAME IN SUBSTANCE USE RECOVERY 15 The painful emotion arising from the consciousness of something dishonoring, ridiculous, or indecorous in one’s own conduct or circumstances (or in those of others whose honor or disgrace one regards as one’s own), or of being in a situation , which offends one's sense of modesty and decency (p. 3). Others, such as Lewis (1992), write that shame is “self-conscious emotions” and Gilbert (2002) states that it is a “multifaceted experience.” Shame cannot be defined in just one way, and it does not appear the same for everyone. It cannot always be identified by a specific facial expression or behavior; instead, it may show up in various ways, such as gaze avoidance or a head down slumped posture, depending on cultural norms and individual differences (Sedighimornani, 2018). These varying definitions of what shame is and how it is expressed lead to questions about how it develops within cultures and its place within individuals’ lives. Many researchers believe that self-conscious emotions such as shame, guilt, and pride develop after birth instead of being present at birth (Lagattuta & Thompson, 2007; M. Lewis, 2000; Tangney & Dearing, 2002). The specific age when a child begins to feel self-conscious emotions remains debated, with some researchers suggesting 15- 18 months and others proposing up to eight years old (Sedighimornani, 2018). While children as young as three may display signs of shame, a more advanced understanding of this emotion generally does not emerge until around seven or eight (Sedighimornani, 2018). Once an individual develops an understanding of shame, the emotion emerges when they notice the difference between their actual and ideal self, meaning the person they are versus who they believe they should be. This awareness, according to Sedighimornani (2018), can lead some individuals to experience a negative self-evaluation, which can also be shaped further by cultural expectations and norms. HEALING SHAME IN SUBSTANCE USE RECOVERY 16 Culture can strongly influence how shame is experienced and expressed across different individuals. Eastern countries such as China, Japan, and India, which are more collectivistoriented countries, have been described as ‘shame societies’ as they tend to see shame as a collective phenomenon that risks shaming the community (Yakeley, 2018). On the other hand, Westernized countries, which tend to be more individualistic, have been described as ‘guilt societies’ (Yakeley, 2018). A shame society uses shame to maintain social order by threatening to alienate an individual from the community, while a guilt society maintains social order by focusing on the feelings of guilt and fear of punishment (Yakeley, 2018). The meaning and function of shame vary across countries and among the cultures within them. In Japan and China, shame is viewed as a social function that promotes group cohesion, while in India, it is seen as a healthy emotion that protects. Both perspectives show that having a sense of shame is important and socially accepted (Yakeley, 2018). While society has a big influence on an individual's understanding of shame or guilt, individuals still develop their own personal experiences of shame. Those with SUDs often carry both shame and guilt, but while guilt is the feeling “I did something wrong,” shame is the deeper belief that “I am wrong,” which makes it especially tied to addiction and its effects on a person's sense of self. Shame and guilt both play powerful roles in addiction and SUDs. They can create a shame spiral or cycle, which refers to a pattern created when an individual tries to escape negative selfconscious emotions from substance use, leading to an increase in shame related to the stigma of being an “addict” (Batchelder et al., 2022). Batchelder et al. (2022) found that addiction is linked to avoidance and can actually maintain the addiction, while guilt is more complex and can be both harmful and sometimes helpful. In some cases, it was found that guilt increases substance use as a form of self-punishment, but in other cases, it can support and motivate repair and HEALING SHAME IN SUBSTANCE USE RECOVERY 17 healing (Batchelder et al., 2022). Some believe that shame and guilt are not inherently good or bad on their own but instead depend on how the individual interprets them. Research suggests that retributive self-blame (“I am the problem”), which is when an individual sees themselves as flawed or unchangeable, causes shame and guilt in a destructive way (Snoek et al., 2021). On the other hand, scaffolding self-blame (“I did something hurtful, but I can take steps to heal and grow”) involves self-compassion and the idea that one is capable of change, which supports recovery and identity rebuilding (Snoek et al., 2021). This approach allows those commonly negative feelings of shame and guilt to be used in a restorative way instead of adding another layer to the shame spiral. The emotional experience of SUDs is not just about the substance itself and what decision the individual makes, but also who they believe they are and who they think they can become. Impact on Identity and Self-worth Identity describes our sense of self, which encompasses all that we want to be and all that we don’t. It creates a sense of belonging and gives “a sense of inner centeredness and valuing” (Kaufman, 1974, p. 568). The search for identity is not easy and can be affected by feelings of shame, which then can turn into hopelessness and worthlessness. Shame and experiences of shame generally start as an attack on one's self-consciousness, which then turns into a harsh judgment of oneself, leading to intense inner suffering (Kaufman, 1974). Extreme shame interrupts the formation of one's identity and can destroy any stable foundation of the inner self (Kaufman, 1974). Kaufman (1974) proposes that true freedom of self can only emerge when individuals stop attempting to be all things and instead move beyond shame and towards selfaffirmation. To move forward, one must shift their attention outward, engage with the world through restoring interpersonal connections with supportive others, approach shame through HEALING SHAME IN SUBSTANCE USE RECOVERY 18 open acknowledgment and validation, and cultivate self-compassion to integrate these experiences into a stable self-affirming identity (Kaufman, 1974). Shame targets the self and not only disrupts identity but also deeply impacts the individual's self-esteem. When a person starts to believe that they are unworthy, flawed, or unlovable, then their capacity to see themselves as being able to grow, connect, and recover becomes weakened. Self-esteem is a central part of understanding how shame operates within SUDs. Self-Esteem in Substance Use and Recovery According to Zeigler-Hill (2013), self-esteem is a very popular topic that has more than 35,000 publications written on it and can be defined as the evaluation of one's worth, including how much a person likes and believes in themselves. Individuals are always trying to achieve higher self-esteem and feel better about themselves. Self-esteem usually relates to various aspects of health and daily life, such as physical health, interpersonal relationships, education, crime, work, and other skills (Zeigler-Hill, 2013). Considering an individual's self-esteem levels is important when diagnosing and picking appropriate treatment as the DSM-5-TR references self-esteem and related terms frequently (Zeigler-Hill, 2013). When self-esteem is low, individuals are more vulnerable to depression, negative feelings of self-worth, and greater difficulty coping with stress or adversity. Research shows a negative relationship between shame and self-esteem because, as shame increases, self-worth tends to decrease (Budiarto & Helmi, 2021). If a person thinks of themself as a bad person, then it's more likely that their self-esteem will decrease, which thus erodes their sense of self and self-worth (Budiarto & Helmi, 2021). Similarly, Yan et al. (2020) studied how self-esteem and self-perception during adolescence later influence substance use problems, which found that people with low self-esteem and social anxiety were more likely to use substances as a coping mechanism. The research studied 19- HEALING SHAME IN SUBSTANCE USE RECOVERY 19 year-olds with negative self-perceptions, and it was found that they had a greater increase in substance use problems by age 27 (Yan et al., 2020). Taking all this into consideration, it becomes important to rebuild self-esteem as part of the recovery process so that individuals can begin to see themselves as capable, worthy, and able to change, which can improve their treatment engagement and progress. This lowered sense of self-esteem can be even more challenging when the individual has a co-occurring disorder, where symptoms can influence each other and make recovery more difficult. Co-occurring Disorders and Dual Diagnosis Co-occurring disorders (CODs) are very common for those with substance use disorders. Rates of CODs tend to be higher in individuals “with antisocial personality disorders (84%), borderline personality disorder (67%), bipolar disorder (61%), and schizophrenia (nearly 50%)” (Douaihy & Daley, 2014, p. 286). Bahji (2024) describes CODs within SUDs as “the rule rather than the exception,” emphasizing how extremely common they are (p. 12). The cooccurrence of SUDS and psychiatric conditions presents challenges when trying to diagnose, find appropriate treatment, and work through the recovery process. Those with CODs tend to have more problems with their family, social life, medical care, and are more likely to relapse (Douaihy & Daley, 2014). Those with dual diagnoses often turn to substances to help them manage their psychiatric symptoms, such as coping with anxiety, depression, trauma responses, medication side effects, and the stigma of having a mental health disorder (Bahji, 2024). When both disorders overlap, shame and self-blame tend to grow stronger, and it can be harder for individuals to feel connected to their identity and self-worth. Treatment needs to support the whole person, not just their substance use, and not just their mental health symptoms. This is HEALING SHAME IN SUBSTANCE USE RECOVERY 20 where recovery becomes more than just stopping the use but also rebuilding the individual's sense of self, self-esteem, and learning new ways to cope. Recovery Recovery is a lifelong process that works to rebuild a meaningful, satisfying, and healthy life beyond substance use. The definition of recovery is different for everyone. The Substance Abuse and Mental Health Services Administration (SAMHSA) (2012) refers to recovery as “a process of change through which individuals improve their health and wellness, live a selfdirected life, and strive to reach their full potential.” In addition, Ashford (p. 5, 2017) says that it is “an individualized, intentional, dynamic, and relational process involving sustained efforts to improve wellness.” Since recovery is different for every individual, it can be measured in terms beyond just that of abstinence, and instead can focus on aspects such as reduced substance use, improved living environment, improved physical health, quality of life, purpose, community, etc. (Douaihy & Daley, 2014). With so many personal and environmental factors involved, individuals in recovery may face a variety of challenges. Challenges Even with support and treatment, the recovery process can be challenging. The process can bring up difficult emotions, relationship changes, and stressors that may create barriers or setbacks. Such barriers include fears, stigma, health insurance, income, family and friends, or even geographical regions. A study by Farhoudian et al. (2022) reviewed 12 systematic reviews that focused on treatment barriers and facilitators for individuals with substance use disorders. The reviewed papers revealed numerous barriers and facilitators that were classified into three levels: individual, social, and structural. The personal level described barriers such as personal fears, beliefs about treatment, and poor coping strategies, while the social level described stigma, HEALING SHAME IN SUBSTANCE USE RECOVERY 21 lack of social support, and the individual's family and friend network (Farhoudian, 2022). The structural level included barriers such as lack of treatment availability, long waitlists, health insurance, and financial obstacles (Farhoudian, 2022). Facilitators were also identified, which consisted of factors that helped an individual stay and succeed in treatment. Some facilitators included personal motivation, family and friends, and the treatment team (Farhoudian, 2022). The studies showed that structural factors were the most reported barriers and facilitators that could either challenge access to treatment or support the individual's recovery process. These challenges can make it hard for an individual to maintain progress, which is why relapse is a common experience in recovery. Relapse Relapse is often part of the recovery process for many, and can happen when the individual feels overwhelmed, unsupported, or unable to cope with stress. It does not represent a personal failure, or that treatment has failed. Douaihy & Daley (2014) describe the difference between lapse, which is a single return to use, and relapse, which is an ongoing use of substances. The first 3 months after treatment are critical for the individual and generally result in higher rates of relapse. Studies vary, but findings show that about half to nearly two-thirds of individuals will relapse after starting treatment (Baltieri, 2003; Sinha, 2011). Within one year of treatment, more than 85% of individuals will relapse and return to drug use (Sinha, 2011). These high rates highlight the need for continued support and skill development rather than shame and discouragement. Along with understanding the barriers to recovery previously mentioned, it’s important to note the possible biological components of relapse. Sinha (2011) shows that relapse is not just behavioral, but that stress hormones and parts of the brain that are linked to craving and self-control can make someone more likely to relapse. For example, higher cortisol levels HEALING SHAME IN SUBSTANCE USE RECOVERY 22 and changes in the brain that are related to self-control have been shown to predict who is more likely to relapse (Sinha, 2011). In addition to these obstacles, new and unexplored trauma can play a major role in an individual's substance use and recovery. Trauma can influence how an individual regulates their emotions and stress, which can hinder their recovery and increase their vulnerability to relapse. Past Trauma Research shows that trauma is highly prevalent among individuals with substance use disorders. Individuals with SUDs typically, but not always, have a history of past physical, sexual, or mental trauma. A comparative study by Belfrage et al. (2023) collected data from two groups: individuals who were currently using substances (active SUD) and individuals in recovery (non-current users). They measured childhood trauma, lifetime traumatic events, PTSD symptoms, and gender differences. Results found that over 70% of participants had experienced childhood trauma, and more than 90% had experienced trauma later in life for both those using substances and those in recovery (Belfrage et al., 2023). Similarly, Keyser-Marcus et al. (2014) found that individuals with SUDs who had past trauma were more likely to experience depression, anxiety, and suicidal thoughts. Those who had experienced both physical and sexual trauma had the highest distress levels (Keyser-Marcus et al., 2014). Trauma can have a huge impact on a person’s life and may contribute to the development of substance use disorders or play a role in maintaining them. Findings from the ACEs study show that early trauma can raise an individual's risk for later substance use (Felitti et al., 1998). Trauma affects emotional regulation, coping, and stress responses, which can make recovery more difficult and raise the likelihood of relapse. The TAMAR model directly addresses all these needs and works to teach individuals the skills needed to support their healing from their past trauma. HEALING SHAME IN SUBSTANCE USE RECOVERY 23 Trauma, Addiction, Mental Health, and Recovery (TAMAR) Trauma, Addictions, Mental Health, and Recovery (TAMAR) was created in the late 1990s as part of a Substance Abuse and Mental Health Services Administration (SAMHSA) project for women incarcerated in Maryland and has since been implemented in many justice systems, behavioral health systems, faith-based programs, and community programs (Smoking Cessation Leadership Center, 2023). TAMAR uses psychoeducation, mindfulness, and creativity to help individuals who have been through traumatic experiences and need to learn or rebuild healthy ways to manage their distress and pain, develop their self-compassion and respect, maintain meaningful connections to others, and find purpose in life (Smoking Cessation Leadership Center, 2023). TAMAR uses psychoeducation to teach individuals how their body and mind responses to stress and trauma, while also teaching self-regulation skills and supporting their self-forgiveness (Smoking Cessation Leadership Center, 2023). The program also works to reduce shame and feelings associated with shame while incorporating creative expression. The TAMAR manual (2023) describes creativity as a “quest for meaning” that allows individuals to rebuild their sense of self, think about what feels safe, expressive, and life-affirming, reframe their experiences, and develop new perspectives (p. 4). Creativity and creative art processes are important parts of addressing healing within the TAMAR manual. Along with creativity, the TAMAR also incorporates mind-body skills into every module to help relax the individuals' fight or flight response system. Using these core elements, the TAMAR manual is organized into a structured series of modules that guide the participants through education, self-awareness, emotional regulation, and self-expression. The TAMAR outlines 15 modules, each of which contain a check-in, a reminder of the session and ethical guidelines, a space for psychoeducation and discussion, mind-body skills, and HEALING SHAME IN SUBSTANCE USE RECOVERY 24 a check-out at the end (Smoking Cessation Leadership Center, 2023). The first modules introduce concepts of trauma and stress responses, while the later modules focus on developing coping strategies (self-soothing, tolerating distress), establishing boundaries, and exploring themes of intimacy, trust, and identity. The last module focuses on reflection and a group-based ritual that focuses on meaning-making and integration. This structure allows for gradual healing and helps the participants feel safer, more in control, and more aware of themselves. This approach is relevant for individuals with substance use disorders, as they tend to struggle with emotion regulation and shame, which often contribute to substance use as an unhealthy coping strategy. These aspects line up with Dialectical Behavior Therapy, which teaches skills for managing emotions, tolerating distress, and interpersonal skills, which support the goals of the TAMAR curriculum. Dialectical Behavior Therapy Dialectical Behavior Therapy (DBT) was created by Dr. Marsha Linehan in the early 1980s, originally to help those with borderline personality disorder who had chronic suicidal tendencies and behavior. DBT is grounded in a dialectical and biosocial theory of psychological disorders, which highlights emotion regulation and the challenges it may pose (Linehan, 2014). DBT works to help individuals learn how to modify patterns associated with behavior, emotions, cognition, and interpersonal interactions, which tend to cause difficulties in daily functioning (Linehan, 2014). Understanding DBT starts with recognizing emotion dysregulation and understanding the nature of emotions. Defining emotions is difficult, and something that many researchers tend to disagree on, but DBT skills view emotions as being quick, automatic reactions in the body and mind in response to both internal and external events (Linehan, 2014). People who struggle with emotional dysregulation tend to often feel painful emotions, have a HEALING SHAME IN SUBSTANCE USE RECOVERY 25 hard time calming down, get stuck on emotional thoughts, think in distorted ways, act impulsively, have a hard time staying focused on goals, or, under extreme stress, they may shut down, freeze, or completely disconnect (Linehan, 2014). DBT focuses on the opposite, emotional regulation, and the ability to apply skills, which then increases the individual's control and stability in managing their thoughts, feelings, and behaviors. DBT skills are broken down into four skill categories: mindfulness, , which teaches individuals to stay aware and in the present moment; interpersonal effectiveness, , which includes skills that are good for communicating needs, setting boundaries, and maintaining relationships (e.g. DEAR MAN, GIVE, FAST); emotional regulation, , which focuses on identifying on recognizing emotions and learning how to change or manage them (e.g. ABC PLEASE and opposite action); and distress tolerance, , which teaches how to handle difficult situations and emotions (Linehan, 2014). These categories become important when we look at the effects of shame and substance use on an individual. Both shame and substance use often involve intense emotions, avoidance, and difficulty with coping. DBT provides a tool that helps individuals respond differently in difficult situations, which makes it appropriate to use in recovery settings. Application to Shame and Substance Use Recovery DBT can be applied to approaching both feelings of shame and SUD. DBT addresses building emotional regulation, distress tolerance, and non-judgmental self-awareness, which targets shame and self-blame that can contribute to substance use behaviors. A randomized clinical trial by Linehan et al. (2002) compared using DBT to using a 12-step approach with opioid dependent women with borderline personality disorder. While both treatments reduced substance use, the DBT group was able to maintain the reductions over time and demonstrated greater accuracy for self-reporting drug use, which suggests that there was a reduction in HEALING SHAME IN SUBSTANCE USE RECOVERY 26 avoidance and shame (Linehan et al., 2002). DBT skills teach individuals lifelong tools that can be used when experiencing shame, urges, and emotional pain. Opposite action, for instance, encourages engagement instead of withdrawal, which goes against the shame spiral. Distress tolerance provides strategies for alternative coping skills when emotions are overwhelming, and Radical Acceptance, which helps individuals reduce self-blame and look at themselves with compassion (Linehan, 2015). These skills work to rebuild a more stable and compassionate sense of identity, which is essential to sustain long-term recovery. Compassion-Focused Therapy Compassion- Focused Therapy (CFT) was created by Paul Gilbert in the early 2000s. CFT was developed for individuals to understand and work with their suffering in compassionate, non-shaming ways, especially for those facing chronic mental-health struggles (Kolts, 2016; Gilbert, 2010). This process focuses on providing individuals with methods to address difficult emotions in situations and looking at them with a compassionate view (Kolts, 2016). Paul Gilbert (2010) mentions that CFT does not try “to soothe away” and avoid painful emotions; instead, it aims to engage in the pain, which can be hard for many who have a fear of compassionate feelings for both themselves and others. CFT is supported by research from evolutionary psychology, affective neuroscience, attachment theory, behaviorism, CBT, and mindfulness (Kolts, 2016). The core model of CFT, also referred to as the Three Circle Model, consists of three main core emotion regulation systems: the “Drive” system, the “Threat” system, and the “SoothingAffiliate” system. The first system, also referred to as the “Drive” mind, represents the mindset of motivation that pushes individuals to seek, argue, and work towards goals (Fraser & Gregory, 2024). This mind focuses on the hard work and determination that is needed to endure and stay HEALING SHAME IN SUBSTANCE USE RECOVERY 27 focused on a goal even when things get tough (Fraser & Gregory, 2024). The second mode is the “Threat” mind, which centers on the evolutionary aspect of the fight or flight response, which was essential for our ancestors' survival and still works to protect us from threats (Fraser & Gregory, 2024). The last system is the “soothing- affiliate” mode, which thinks about the body's emotional regulation system and its ability to self-soothe and calm the nervous system through breathing techniques, relaxing the body, and feeling safe (Fraser & Gregory, 2024). This model is commonly visually represented by a blue circle (Drive), a red circle (Threat), and a green circle (Soothing), which are all connected by arrows showing the way that these systems interact and influence each other. Along with the core model, CFT also focuses on core treatment components such as psychoeducation about de-shaming, understanding the three-circle model, guiding them through compassion-based skills like empathy, mindfulness, coping with difficult feelings, and working through fears and obstacles (Kirby & Gilbert, 2017). These skills and framework support overall emotional well-being and provide a foundation for addressing a variety of different mental health conditions, such as depression, trauma, anxiety disorders, eating disorders, personality disorders, and addiction and substance use disorders. Application to Shame and Substance Use Recovery Compassion- Focused Therapy (CFT) can be applied to the treatment of shame and substance use when an individual is focused on their recovery. To understand the application, it’s important to recognize the connection between shame and the social threat it poses. While many will say they are not, humans are social creatures who want to be accepted by others and have a sense of belonging (Lee & James, 2011). This concept can activate a sense of social threat, which refers to the way people view themselves and how they think that others view them; this tends to pose a danger to their mental and emotional well-being (Lee & James, 2011). Once an HEALING SHAME IN SUBSTANCE USE RECOVERY 28 individual begins to both understand and appreciate their social brain, they can then start to develop their compassionate mind (Lee & James, 2011). Dealing with feelings of shame, disgust, fear, and anger starts with learning how to calm ourselves through compassion and selfunderstanding. According to Lee & James (2011), there are three important types of mindsets: the threat-focused mind, the traumatized mind, and the compassionate mind. The threat focused mind is one that is easily activated and works to detect and respond to what our brain perceives as dangerous (Lee & James, 2011). This mindset can lead to anxious thoughts and possible imagery, which can then lead to anger towards oneself or even others. The traumatized mind focuses on past threats, which may result in intrusive thoughts or flashbacks, and the compassionate mind, which looks at the world through a lens of compassion, caregiving, and kindness (Lee & James, 2011). Switching from one mindset to another is not an easy thing to do and requires one to prepare their mind to function compassionately. Mindfulness teaches individuals to pay attention to what is happening in their minds and to be aware of the present moment. Techniques such as mindful breathing, mindful attention, and soothing rhythm breathing can start the journey to becoming more mindful and opening space within our mind to notice threat-based and traumatized mindsets (Lee & Johnson, 2011). Along with preparing our brain for switching mindsets, individuals can also stimulate their minds and bodies to feel compassion by using imagery exercises. Compassionate imagery exercises are designed to replace the negative emotions and images that we hold in our minds with positive images that will soothe the brain and thus calm the threat mindset (Lee & James, 2011). An example of this is developing and having a safe place to visit in the mind. A safe place can resemble a real place that the individual feels safe in, or it can be a place that only exists in the human mind (Lee & James, 2011). Another exercise that can help develop skills of compassion is compassionate HEALING SHAME IN SUBSTANCE USE RECOVERY 29 letter writing, where an individual focuses on writing a letter to themselves encompassing support, understanding, and kindness as they work through their traumatic experiences (Lee & James, 2011). Using CFT to address feelings of shame, low self-esteem, and self-worth has emerged as a therapeutic approach for individuals who are struggling with substance use disorders. While CFT is a fairly new therapy, some studies have begun to research its effects, feasibility, and overall effectiveness. Ma et al. (2025) systematically reviewed 12 studies with 786 participants that assessed the impact of self-compassion-focused interventions with individuals with substance use disorders. All studies reviewed addressed self-compassion and/or were related to other mental health factors such as mindfulness, depression, stress, and drug cravings (Ma et al., 2025). Overall, the results showed that self-compassion focused interventions had both an overall medium, meaningful but not large, effect on the participants’ self-compassion and in improving their mindfulness and depressive symptoms (Ma et al., 2025). Although improvements were observed in these areas, the interventions did not show significant progress in psychological flexibility, stress, and PTSD symptoms and showed no meaningful reduction in craving (Ma et al., 2025). This could be due to the specific and heightened distress that those with SUD face, such as stigma, trauma, shame, discrimination, and the neurobiological mechanisms of craving (Ma et al., 2025). Along with these results, Carlyle et al. (2019) created a mixed-methods study that measured the feasibility and acceptability of CFT with individuals with opioid use disorder (OUD). The study incorporated psychoeducation on compassion and self-compassionate exercises for three 2-hour sessions over three weeks (Carlyle et al., 2019). The findings indicated that the intervention is feasible and had positive effects on reducing criticism, facing negative emotions, helping the participants learn more about themselves, and decreasing depression and HEALING SHAME IN SUBSTANCE USE RECOVERY 30 stress (Carlyle et al., 2019). Along with these positive outcomes, concerns arose regarding participants having greater desires to use opioids at the end of the intervention, suggesting the need for caution and additional research. Compassion-Focused Therapy provides a structured framework for addressing shame and emotional regulation that can be applied when working with individuals who have a SUD. Along with this framework, art therapy could offer a complementary approach that allows these concepts to be explored through creative expression. Art Therapy Art therapy provides a creative and expressive way for individuals to explore their emotions, identity, and personal experiences through the recovery process. It can help individuals work through tough feelings of shame, guilt, and low self-esteem while supporting the development of purpose, emotional regulation, and self-worth. According to Schmanke (2016), art therapy has been used in substance use treatment since the 1950s and supports recovery by helping clients express difficult emotions, especially when verbal communication feels unsafe or too overwhelming. Shame is a major barrier in substance use treatment and is tied to identity disruptions, but the art-making process allows these individuals to externalize these experiences and reconnect with a more compassionate and stable sense of self (Schmanke, 2016). When used in group settings, art therapy can help reduce isolation, support feelings of belonging, and foster shared understanding (Schmanke, 2016). Shame is heavy, private, and often carried in silence, but art therapy gives individuals a chance to visualize it and see what they feel rather than be defined by it. Externalizing Feelings of Shame Through Creative Processes Feelings of shame are often hidden away and not talked about, so when an individual engages in talk-based treatment, they may have trouble verbalizing their emotions. Art therapy HEALING SHAME IN SUBSTANCE USE RECOVERY 31 offers a non-threatening way to explore these experiences by allowing individuals with SUDs to externalize their internal conflicts and receive support and compassion from others. Horay (2006) emphasizes the ambivalence, avoidance, and emotional guardedness that are common in substance use treatment. Horay (2006) used “incident drawings” where individuals create artwork depicting a specific moment related to their substance use, to help promote the externalization process and reduce shame-based avoidance. These drawings also helped to increase emotional insight and support the clients as they moved from ambivalence towards a readiness to change (Horay, 2006). When using these drawings with individuals, it was found that many were more willing to talk about their difficult experiences, shame and guilt became easier to discuss, and they were able to reflect on their experiences safely, see new perspectives, and begin to shift self-blame into understanding (Horay, 2006). Reflecting on their experiences also allows individuals to learn and work on their own self-compassion skills. Once shame is externalized, individuals can start to see themselves better and work to restore their self-esteem and self-worth. Rebuilding Self-esteem and Self-worth Art therapy can help individuals with SUDs heal from their emotional trauma, increase their self-awareness, and teach them how to use self-reflection. Research has shown that providing a safe emotional outlet allows feelings to be expressed freely, and the incorporation of art therapy reinforces a sense of competence and mastery that can help foster positive feelings about the self (Shukla et al., 2022). Art therapy also helps people to see themselves and their emotions more clearly, increasing their insight, self-awareness, and reflection (Shukla et al., 2022). Patil et al. (2022) conducted a study of 17 male participants who went through 30 artsbased therapy sessions within three months. The study used the Rosenberg Self-Esteem Scale HEALING SHAME IN SUBSTANCE USE RECOVERY 32 and the Difficulties in Emotional Regulation Scale, which found that there were significant improvements in self-esteem and emotional regulation, which were associated with lower absenteeism. As self-esteem strengthens, so does self-compassion, allowing individuals to view themselves as capable of change and increasing their motivation and engagement in recovery. Once the foundation for self-worth is laid down, the next step is tackling emotional resilience and developing coping skills to regulate difficult emotions and situations. Develop Coping Skills and Emotional Regulation With a stronger sense of self beginning to form, individuals can start learning new ways to cope with stress and uncomfortable emotions in ways that are healing instead of harming. Many individuals who have substance use disorders never learn the skills needed to handle life and all its challenges; instead, they use techniques like black and white thinking, denial, avoidance, and substance use (Buchalter, 2011). Coping skills help increase healthy decisions, increase self-awareness, and knock down barriers, which help individuals to realize that they have choices on how to react (Buchalter, 2011). Doing these things shifts the focus from a negative viewpoint to one that is positive, which thus increases self-esteem (Buchalter, 2011). Art therapy allows individuals to practice radical acceptance and willingness when materials do not behave as expected, allowing them to experience frustration and learn how to be present with it (Clark, 2017). One art therapy directive that supports coping and emotional safety is the Safe Place Drawing, which helps individuals visualize and create an image of a calm internal space where they can mentally return to during overwhelming moments. This process helps them to feel comfortable and learn how to access that state when they feel distressed. Along with developing coping skills, art therapy can also help individuals learn emotional regulation through mindfulness, metaphor, and mastery (Clark, 2017). Making art can HEALING SHAME IN SUBSTANCE USE RECOVERY 33 be a form of meditation that helps to focus and open the mind to the present moment. Art therapy also allows room for metaphors, which can be a good way for individuals to visualize their emotions and form connections (Clark, 2017). Lastly, mastery, which includes choosing one enjoyable and slightly challenging activity each day to help rebuild confidence, self-belief, and a sense of accomplishment (Clark, 2017). As individuals learn how to manage their emotions and care for themselves, the next connection becomes essential, which is finding community and belonging in the recovery process. Foster Community and Reduce Isolation Community and social connection are important for those experiencing SUDs, as shame and stigma can tend to cause the individual to withdraw from others, which can impact their recovery. Group art therapy provides a space where individuals can share experiences, witness one another, and feel a sense of belonging. Toll (2024) describes art therapy groups as “safe havens” that work as sanctuaries of reconnection that offer warmth, shared presence, and community support. Collective creative environments help counter loneliness, work on interpersonal relationships, and support the emotional well-being of individuals as they get to feel seen and understood with others who are also healing. Best et al. (2016) emphasizes that recovery is a social process where there is a shift from an “addict intensity” associated with shame and isolation to a “recovery identity” that is supported by meaningful community connections. Belonging to supportive groups has many positive aspects, such as strengthening motivation, increasing hope, and providing social and emotional resources (Best et al., 2016). Community art therapy experiences reinforce that recovery is not something that an individual can achieve alone, but something that can be supported by others who are also going through recovery. HEALING SHAME IN SUBSTANCE USE RECOVERY 34 Conclusion The literature shows that substance use disorders are deeply connected with experiences of shame, identity disruption, low self-esteem, and emotional distress. Shame functions as both a cause and a consequence of substance use, which leads to individuals withdrawing, isolating, and struggling to view themselves as being worthy of change. These emotional challenges are increased when either co-occurring disorders or past trauma are present, which makes recovery a complex process. Therapeutic approaches and frameworks that address both emotional regulation and self-compassion include the Trauma, Addictions, Mental Health, and Recovery model, Dialectical Behavior Therapy, and Compassion- Focused Therapy. These approaches offer meaningful and helpful strategies to reduce shame and rebuild one’s sense of self. Art therapy also works to provide a creative route for externalizing emotions, rebuilding self-worth, developing coping skills, and fostering connections with others. These findings highlight the importance of treatment that addresses not only the behavioral aspects of substance use but also the emotional and social aspects of healing. The following section provides an art-based curriculum designed to support recovery through expression, self-compassion, and community (see Appendix A). HEALING SHAME IN SUBSTANCE USE RECOVERY 35 Section III: Methodology This section outlines a curriculum created for clinicians to use with adults who are struggling with substance use disorders (SUDs) (see Appendix A). The curriculum focuses on addressing shame and its impact on an individual's identity, emotional functioning, and recovery process. The curriculum consists of art therapy interventions used in group therapy sessions that are based on the Trauma, Addictions, Mental Health, and Recovery (TAMAR) model, Dialectical Behavior Therapy (DBT), and Compassion-Focused Therapy (CFT). The interventions used will be implemented over 60 days (eight weeks) with two sessions each week in an inpatient treatment setting. Each intervention will focus on building skills related to emotional regulation, mindfulness, distress tolerance, developing compassion, rebuilding identity, self-esteem, and strengthening connections to others. Target Audience The curriculum is designed for master-level licensed art therapists with prior knowledge of SUDs to use with adults receiving inpatient treatment for SUDs (see Appendix A). Participants should complete the detoxification process and be medically and psychologically stable enough to engage in group sessions. Individuals should be able to remain alert and coherent throughout discussions and art-based interventions. This population often experiences shame, past trauma, obscured self-identity, and emotional dysregulation that interferes with their recovery process. Many individuals in an inpatient setting might feel emotionally overwhelmed, judged, and have low self-worth, which may limit their insight and openness. This curriculum provides a safe space for individuals to express themselves, explore, and rebuild identity, which can reduce defensiveness, increase engagement, and support clients who struggle with verbalizing difficult emotions. HEALING SHAME IN SUBSTANCE USE RECOVERY 36 Curricular Structure The curriculum is intended to support adults in inpatient treatment by offering strengthbased interventions that promote insight, emotional stability, and resilience (see Appendix A). It also helps individuals reconnect with their sense of self, which is essential to maintaining lifelong recovery. These goals are supported through a curriculum that draws from TAMAR, DBT, and CFT, each adding different elements to emotional healing and skill development. This curriculum is based on two theoretical approaches, DBT and CFT, which help guide the curriculum in developing new coping strategies, understanding the threat and soothing systems, and building self-compassion (see Appendix A). It is modeled after the TAMAR framework, which helps shape the overall structure of each session through mindfulness, psychoeducation, expressive art making, and reflection. Together, these three approaches offer a balanced combination of skills that support clients in processing shame and rebuilding identity. The curriculum is organized into eight themes covered over a 60-day inpatient stay with two weekly 90-minute group art therapy sessions (see Appendix A). Each session follows a structured schedule starting with a mindfulness warm-up to help clients regulate and come to the present moment. This is then followed by time for art making based on an art therapy directive that is aligned with the week's theme, drawn from TAMAR, DBT, and CFT frameworks. Each session will close with reflection and optional sharing with the group. Early sessions will focus on safety, emotional awareness, and expression, while later sessions will gradually transition to rebuilding identity, self-compassion, and resilience. Throughout the process, shame reduction and the integration of new coping skills will remain key goals. Curricular Outline HEALING SHAME IN SUBSTANCE USE RECOVERY 37 This section outlines the structure of the eight-week curriculum, which includes two 90minute group art therapy sessions each week (see Appendix A). Each week is centered around one main theme, which will be explored in greater depth through the course of two sessions. Each session will follow a consistent schedule: Group Art Therapy Plan GROUP OBJECTIVE(S)/GOALS Goal and Objectives: INTRODUCTION: APPROX. 5 MINUTES Mindfulness Activity (Approx. 3-5 minutes) MATERIALS & MEDIA MAIN ART INTERVENTION/EXPERIENTIAL/DIRECTIVE (APPROX. 60-65 MINUTES) Name: Main intervention steps: SHARING/DISCUSSION/REFLECTION (APPROX 15-20 MINUTES) Processing Questions The leader will provide a moment for any final thoughts or feedback for others. The leader will then thank them for sharing and being open during this process. Week 1: Safety, Identity, and Grounding Session 1: Introduction to Safety and Group Expectations Mindfulness Activity: Grounding Through Senses (5-4-3-2-1) Art Therapy Directive: “Safety looks like...” Session 2: Identity and Self-Awareness HEALING SHAME IN SUBSTANCE USE RECOVERY Mindfulness Activity: Grounding Through Observation Art Therapy Directive: Identity Boxes Week 2 Theme/topic: Shame, Stigma, and Trauma Responses (CFT) Session 1: Understanding Shame and How It Shows Up Mindfulness Activity: Thought and Emotion Awareness Art Therapy Directive: Shame Mapping Session 2: Threat-Drive-Soothing Systems (CFT) Mindfulness Activity: Breath and Body Soothing Art Therapy Directive: Threat-Drive-Soothing Systems Collage Week 3 Theme/topic: Emotional Regulation and Coping (DBT) Session 1: Emotion Awareness and Naming Mindfulness Activity: Emotion Mapping Art Therapy Directive: Emotion Wheel Expression Session 2: Distress Tolerance Skills (TIPP/Self-Soothe) Mindfulness Activity: Body Scan Art Therapy Directive: TIPP Skills and Regulation Drawing Week 4 Theme/topic: Self-Compassion and The Compassionate Self (CFT) Session 1: Inner Critic and Compassionate Voice Mindfulness Activity: Kind Self-Talk Art Therapy Directive: Finding Compassionate Voice Session 2: Compassionate Imagery and Self-Kindness Practices Mindfulness Activity: Heart-Centered Grounding Art Therapy Directive: Safe Place Visualization 38 HEALING SHAME IN SUBSTANCE USE RECOVERY Week 5 Theme/topic: Rewriting your Story (TAMAR and CFT) Session 1: Past Narratives Mindfulness Activity: Grounded Breathing Art Therapy Directive: Container of the Past Session 2: Reframing and Rewriting Your Story Mindfulness Activity: Perspective Taking Art Therapy Directive: Blackout Poetry Week 6 Theme/topic: Relationships, Boundaries, and Belonging (DBT) Session 1: DBT Interpersonal Effectiveness (DEAR MAN/GIVE) Mindfulness Activity: Wise Mind Reflection Art Therapy Directive: Circles of Belonging Session 2: Relationship Connections and Support Systems Mindfulness Activity: Mindful Listening Art Therapy Directive: Communication Mapping Week 7 Theme/topic: Growth, Strengths, and Values (DBT and CFT) Session 1: Identifying Strengths Mindfulness Activity: Strength Reflection Art Therapy Directive: Strengths Zine Session 2: Values, Goals, and Identity Mindfulness Activity: Self-Reflection Art Therapy Directive: Identity Zine Week 8 Theme/topic: Integration and Ritual of Transformation (TAMAR) Session 1: Integration of all Themes (Reflection of Journey) 39 HEALING SHAME IN SUBSTANCE USE RECOVERY 40 Mindfulness Activity: Body Scan Art Therapy Directive: Group Journey Reflection Session 2: Ritual of Transformation/Closing Ceremony Mindfulness Activity: Grounding Through Observation Art Therapy Directive: Reflection of Growth Conclusion This eight-week curriculum brings together DBT, CFT, and the TAMAR model to create a structured and safe way to explore shame, identity, emotional regulation skills, self-awareness, and self-compassion during inpatient SUD treatment (see Appendix A). Since participants may struggle to talk about their emotions, the addition of art therapy offers a nonverbal creative outlet where they can process feelings and explore their experiences. Each week’s theme helps participants gain another layer of insight and skill development that they can use to strengthen their resiliency and use throughout their lifelong recovery. HEALING SHAME IN SUBSTANCE USE RECOVERY 41 Section IV: Curriculum This section presents an art therapy curriculum for clinicians working with adults receiving treatment for substance use disorders (SUDs) (see Appendix A). It is designed to help address shame and support identity development through structured groups, which are based on Dialectical Behavior Therapy (DBT), Compassion-focused therapy (CFT), and the Trauma, Addictions, Mental Health, and Recovery model (TAMAR). Since shame can sometimes be hard to process through traditional talk therapy, this curriculum was developed to address the need for interventions that directly target shame in substance use recovery. Its development is influenced by both personal and clinical observations of how shame can contribute to continued substance use and relapse. The curriculum provides a different way to explore shame within a group setting using art therapy as the primary intervention. The curriculum, titled Healing Shame in Substance Use Recovery through Art Therapy, begins with an introduction on shame and how art therapy, especially in a group setting, can foster expression, identity development, and connection (see Appendix A). The curriculum also includes resources such as a Spotify playlist that can be used during sessions and was developed from music recommendations shared by clients in a mental health recovery center. The curriculum then outlines the target population, group structure, clinician or facilitator qualifications, theoretical frameworks, and notes for adaptation. A table of contents is included to support navigation. The main content of the curriculum is divided into eight weeks, with two sessions per week. Each week focuses on a central theme based on DBT, CFT, or the TAMAR model, and each session includes a specific subtopic. Sessions contain a titled art therapy directive, goals and objectives, an opening mindfulness activity, required materials and media, step-by-step directions, and a closing discussion with processing questions. Following the eight- HEALING SHAME IN SUBSTANCE USE RECOVERY 42 week curriculum is a resource section with printable materials that can be used for specific directives. Conclusion The curriculum, Healing Shame in Substance Use Recovery through Art Therapy, is designed to address shame in adults with substance use disorders using a structured group-based approach (see Appendix A). It is organized into an eight-week curriculum with different art therapy directives each week to help individuals explore difficult experiences, build insight, and develop healthier ways of coping. Overall, this approach helps individuals as they explore and work through shame while strengthening their sense of self within the recovery process. HEALING SHAME IN SUBSTANCE USE RECOVERY 43 Section V: Discussion This section will focus on findings related to shame in those with substance use disorders and the role of art therapy in addressing these experiences. It will also explore treatment methods, limitations, and areas for future research. Shame plays an important role in the context of treatment and recovery, and it is important to discuss how these findings relate to the future of mental health. Brief Summary of the Research Research shows that shame is deeply connected to substance use disorders and can have a major impact on an individual's identity, self-esteem, and emotional functioning. Shame tends to act as both a cause and a consequence of substance use, which can lead individuals to withdraw, isolate, and struggle to see themselves as being worthy of change. Shame is often experienced as an internal and deeply personal emotion, which makes it difficult to recognize and address in treatment. Their lived experiences are often connected to past trauma, stigma, and emotional distress, which can make recovery more complex and increase the risk of relapse. Approaches such as Dialectical Behavior Therapy (DBT), Compassion Focused therapy (CFT), and the Trauma, Addictions, Mental Health, and Recovery Model (TAMAR) have been shown to help address these challenges. These frameworks support emotional regulation, selfcompassion, and the rebuilding of identity. Research also highlights the importance of connection and community within recovery. Supportive group environments can help to increase motivation, hope, and inspire a sense of belonging. Along with these, art therapy also provides a creative way for individuals to explore and process their experiences while helping to externalize their emotions, build coping skills, and strengthen their connections with others. Discussion HEALING SHAME IN SUBSTANCE USE RECOVERY 44 The findings from this research highlight how important it is to directly address shame within substance use treatment (see Appendix A). Shame appears to play a key role in how individuals view themselves and their ability to engage in recovery. This can impact their motivation, connection, and long-term goals. When shame is not addressed, it can contribute to continued substance use, relapse, and difficulty forming a strong sense of identity. From both personal and clinical experiences, shame often goes unspoken but continues to influence behaviors. Individuals may struggle to express or even recognize their shame, which can make it difficult to address. Shame is a hidden experience that requires support and acknowledgement, both individually and within society. This shows the need for interventions that directly target shame and allow individuals to explore their experiences in a different way. Art therapy offers a unique way to engage with shame by allowing individuals to externalize their internal experiences and reflect on them in an easier and more creative way. Using a group setting can help reduce isolation and help individuals feel less alone in their experiences. Having seen firsthand the impact of community and shared experiences, treatment for substance use disorders should include approaches that address both the emotional and social aspects of recovery. Integrating art therapy allows individuals to be better supported when working through shame and rebuilding their sense of self. Limitations One limitation of this study is that the curriculum was based on existing research and has not yet been implemented and evaluated (see Appendix A). Because the curriculum has not yet been tested in a clinical setting, its effectiveness in reducing shame or improving treatment outcomes cannot be determined. A second limitation is that the curriculum is designed for a specific population of adults in treatment settings, which may limit whether it is applicable to HEALING SHAME IN SUBSTANCE USE RECOVERY 45 other populations or levels of care. Individual differences such as background, culture, readiness for change, and engagement in treatment may also have an impact on how individuals respond to the directives. A third limitation is that the curriculum was developed from the perspective outside of the target population. While it was informed by personal and clinical observations, this perspective is different from the experiences of individuals with SUDs and may have influenced the development of the curriculum. Suggestions for Future Research Future research should focus on implementing and evaluating this curriculum in a clinical setting to better understand how effective it is in addressing shame in substance use recovery (see Appendix A). It may also be helpful to explore how different individuals respond to art therapy directives and which they find most meaningful or impactful. Including a pre- and postassessment could help measure changes in shame and other outcomes over time. Additionally, future studies could look at how this curriculum could be adapted for different populations or treatment settings and the long-term effects on shame, identity development, and relapse prevention. Conclusion Shame is a core experience that can impact how individuals view themselves, relate to others, and engage in treatment. When shame is left unaddressed, it can influence behavior, reinforce isolation, and increase the risk of relapse. This research explores the role of shame in substance use disorders, its connection to trauma and stigma, and the importance of addressing it in treatment. The development of the curriculum, Healing Shame in Substance Use Recovery through Art Therapy, provides a structured approach for addressing shame through the use of art therapy and group-based interventions. Addressing shame is an essential part of treatment that HEALING SHAME IN SUBSTANCE USE RECOVERY 46 can help support a more meaningful and lasting recovery. 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