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

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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.

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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

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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

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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).

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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).

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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

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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

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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,

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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

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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).

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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

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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

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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:

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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.

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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

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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

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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-

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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

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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,

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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

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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.

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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).

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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.

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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

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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

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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

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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

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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.

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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-

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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.

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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

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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

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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

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46

can help support a more meaningful and lasting recovery. By integrating art therapy, individuals
are given the opportunity to explore and work through shame in new ways that can help to build
insight, connection, and a stronger sense of self.

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47

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Appendix A

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