I have had several requests lately for information on how Self-Acceptance Psychology reframes emotional and behavioral problems. Rather than using the false “disease model” of “mental disorders” advocated for decades by psychiatrists and the Diagnostic and Statistical Manual (DSM-5), my new paradigm states that psychological problems are nearly all related to feelings of low self-worth and shame. Poor shame tolerance is caused by an interaction of Five Causative Factors: fear, shame, fear of social exclusion, trauma and attachment status.

While the DSM subdivides and categorizes mental issues in irrelevant ways that confuse, Self-Acceptance Psychology simplifies. All “mental disorders” can be considered one of three blame-shiftng behaviors: Other-blaming, Self-blaming and Blame Avoidance. There is much more in my book on this topic, but here is one case from that book, with the client’s presentation on the lefthand column and the SAP Case Formulation in the righthand column.

Clinicians and others must begin to wean themselves off the false belief that some alleged “neurochemical imbalance” is occurring in the brain and understand that human behavior is caused by human emotions and thoughts — nothing more complicated than that! We do not need to medicate someone who is merely feeling low self-worth and shame! Instead, teaching that person to be self-accepting provides real, life-long solutions to their emotional struggles.

Client Presentation and History

Traditional Diagnosis: Attention-Deficit/Hyperactivity Disorder (ADHD) and Oppositional Defiant Disorder (ODD)

Connor is a 9-year-old male who has classic hyperactivity and attentional issues, along with disobedience directed only at his mother. He has a pattern of becoming angry when disciplined, but also clinging to his mother in fear. He texts or calls incessantly when she leaves and does not calm down until she returns. He becomes enraged to the point of punching holes in the wall and slamming doors 100 times. Rages began as a toddler.

Self-Acceptance Psychology Case Formulation (In Italic)

Connor clings because he is overly attentive to and solicitous of his mother, a clear sign of attachment distress. Both children and adults engage in clinging and pursuing behaviors when they have insecure attachment patterns.

Many clinicians might miss the clinging behaviors by over-focusing on the more “problematic” oppositional behaviors. They are related. Children who feel fundamentally safe are much less likely to become fearful and then enraged. Connor is alternating between various responses in an attempt to find a solution that helps him feel safe and calm down. He is seeking emotional connection that is not inherently present in his family.

Hyperactivity and attentional symptoms are merely indicators of an elevated threat/arousal response. 

Oppositional behavior when criticized indicates oversensitivity to shame and difficulty hearing criticism and responding with equanimity.   

ADHD symptoms include fidgeting, lack of focus, hyperactivity, difficulty doing homework, and homework refusal.

ADHD symptoms can be seen as hyper-awareness to threat (sensory sensitivity, lack of focus) and hyper-reactivity to threat (fidgeting, emotional dysregulation). Clearly, something is making Connor worried and fearful. I see many clients with ADHD who also report shameful thoughts intervening while they are reading or doing homework (“I can’t do this,” “I am a slow learner,” “I will never learn to do math,” “I don’t want to make a mistake,” etc). Internal self-shaming messages trigger the fear response, leading to distracted thinking, poor memory, low self-motivation, and poor performance. 

His father is an alcoholic, has frequent rages, blames others extensively for his problems. Father gets angry, then leaves the home, and did this throughout Connor’s childhood. 

Connor has learned to model his father’s rage and emotional dysregulation. He has also learned that conflict in relationships involves anger, and that issues and emotions are not mended but are unresolved. Father is modeling poor shame tolerance. Connor learned that children are abandoned physically and emotionally by adults who are unable to manage their own emotional needs and distress. Alcohol is a sign of the father’s substitute attachment pattern and likely high levels of anxiety and shame that he is self-medicating with alcohol. Addictions are an indication of poor bonding in the addict’s childhood, indicating that they lack the experience of being compassionately cared for, and making it unlikely that they will know how to bond or connect well with their children. 

Connor has learned that relationships are not about mutual caring, trust, and safety. 

Poor impulse control is a sign of seeing threats where there are none, being triggered into the fear response easily, and over-reacting to threat.  Connor’s parents have consistently modeled anger and are highly anxious, so he does not feel calm. They do not provide emotional attunement and responsiveness to help him learn to regulate emotions in a safe environment.  

Connor rages to the point of blackout and reports enjoying feeling exhausted after his rages.

This is clearly a sign of the threat response. Connor has learned an unhealthy way to regulate his emotions. He has trained himself to actually become enraged, because it leads to an eventual reduction in stress neurochemicals and to feelings of calm, which are more enjoyable than the chronic anxiety he experiences.

Connor used to get good grades in school, but now gives up easily and has low motivation.

Homework and school resistance are indicative of avoidance of shame and the “fold” response of the threat system. He feels shame and it seems emotionally safer to give up, rather than try hard and fail. If he tried and got a low grade, this would merely confirm his perceived inadequacy. Those who do not have good self-acceptance do not have the skill of providing themselves with compassion and warmth in the moment of failure or when they feel inadequate. They avoid experiencing shame because they do not have the emotional resources with which to meet it.

When he was a toddler, Connor’s parents used timeouts and “consequences” to enforce behavior.

Children who are isolated when they are angry are taught that normal emotions are shameful. Timeouts isolate a child during emotional distress and teach a child to self-soothe at an inappropriately early age. They do not get comfort and learn to manage emotions with the help of regulated parents. Parents should provide emotional comfort and soothing instead of timeouts. Consequences force a child to use the pre-frontal cortex at a moment when they are emotional and at an age when this brain area is not fully developed. Children will then “fail” to behave correctly, leading to feelings of shame. They learn to think: “Why can’t I control myself?”, even though this is not an age-normal behavior, especially when the child is upset. 

Mother is highly anxious in presentation, has extremely pressured speech, fidgets excessively, and cries easily in Connor’s presence.

Children are very attuned to a parent’s emotional state starting in infancy. Parents who are anxious or depressed signal this to a child nonverbally, triggering the child’s primal threat response system. A child subconsciously becomes vigilant: “If my parent is worried, perhaps we are in danger.” Parents must be calm to help a child be calm. 

Anxious or depressed parents are also less likely to be attuned to a child’s needs because they are highly focused on getting their own attachment needs met.

Connor bangs his head on walls. He says he will kill himself or “Why don’t you just kill me.” Says he is hurting inside. Connor states he feels he is “stupid, crazy, a psychopath and everything is wrong with me.” 

Suicidality and this level of self-loathing are clearly indicative of Self-Blaming behaviors. His statements are obvious commentary about shame, self-judgment, and low self-worth. Many children, such as Connor, alternate between the three Blame-Shifting Strategies, trying to find a solution to handle their difficult emotions and thoughts.  Unfortunately, many clinicians and parents will become distressed at this behavior, not realizing the real causes of it, and they will quickly jump to hospitalize or medicate.

Becomes enraged when corrected, especially when mother is getting ready to leave the home. Lashes out at siblings, argues, is oppositional about minor items, says “no” to everything parents suggest, pursues parents to argue with them, cannot back down. 

If a child becomes dysregulated when disciplined, it is likely a sign he cannot tolerate shame. Low self-worth and shame are at the core of oppositional behavior. Many of his behaviors indicate “Other-Blaming” behaviors. 

Most parents and therapists focus on the behavior only, not the causative emotion. They try behavioral approaches and medications, both of which trigger additional shaming messages to the child — “I am defective and ‘crazy’. I need drugs to fix my broken brain. I am unable to control myself without these drugs.” 

Using the Self-Acceptance Psychology paradigm, therapists normalize this behavior as fearful and then place the blame where it should be — with the parents. Children naturally want to please parents. If they are oppositional they have given up on pleasing the parents due to lack of attachment. Lack of pro-social emotions, such as caring and empathy, are signs the child has not been treated with care and empathy  — leading to insecure attachment. A child who cannot care for others is in “survival mode” and “living in the limbic system,” making pro-social emotions very difficult to generate, as the mid-brain and cortex are essentially offline during primal threat experiences.

Lack of pro-social emotions also speaks of a lack of self-compassion: A person who has given up caring about others likely also has given up caring about himself.

Connor’s mother has a permissive parenting style. She is not firm and assertive, often because she feels guilty about the divorce. She tells Connor he is the “man of the house” now that the father is not present.

His father has not been involved in Connor’s care and works a lot, leaving Connor to feel abandoned.

The mother’s permissive parenting style is signaling she is not in charge and she has even said as much. Connor feels pressure to be “a man,” so he makes attempts to be in charge through oppositional behavior. He does not know how to be in charge in healthy ways because he is a child, so he does it with extremes of tantrums, rage, opposition, etc. However, when he behaves this way, he feels he has failed in this duty and blames himself. An ineffective, weak parent can make Connor feel unsafe, making him chronically anxious.

Does not like it when others get upset, especially mother.

He feels he is a burden because he made others upset, a sign of Self-Blaming behaviors.

Parents over-focus on behaviors and under-focus on emotions.

Parents who over-focus on behavioral correction are under focusing on emotional attunement. 

Children are just learning how to behave. So when parents over-focus on behaviors a child learns he only gets approval through good behavior. When he misbehaves, which is normal, but his parents over-react, he then experiences failure and shame. He concludes he is unworthy of love. Under-focus on emotions leads to insecure attachment, further reinforcing messages of unworthiness. 

His mother is overly involved in supervising homework, chores, etc. She wants to rescue Connor from his feelings and is afraid of his strong emotions. 

Intrusive parenting signals to a child that he cannot perform on his own and leads to feelings of inadequacy, fears of failure and, eventually, low motivation. Many adults also have low motivation because they fear failure. 

Both parents denigrate each other, telling Connor that the other parent is a “bad parent.” His father told Connor his mother did not want him. 

His mother cries in front of Connor, overshares about marital conflict and divorce, overshares about the failings of his father. 

His mother cannot handle her own emotional state, signaling to Connor that she is not there for him and that he must defer to her emotional needs — a clear sign of lack of secure attachment. Narcissistic or Other-blaming parents lack the empathy and self-awareness to truly care for others. Her over-sharing of adult situations and emotions also may trigger him into a fearful response, because as a child he is not equipped to manage these thoughts and emotional experiences. Parents who lack secure attachment over-focus on problems in their marital relationship, which causes them to under-focus on a child’s needs. Parents who cannot resolve their own attachment needs are not likely to raise securely attached children. 

When his father calls on the phone and asks “How was your day,” Connor becomes irritated because “Dad asks too many questions.” 

When I pursued this idea more deeply with Connor, he said that when his father asked questions it “makes me afraid I’ll give the wrong answer.” Look for any signs of perfectionism or fear of failure as clues to shame.