Research reportComplex trauma and intimate relationships: The impact of shame, guilt and dissociation
Introduction
Complex PTSD has been described as a relational disorder with its antecedents in relational trauma (e.g., Ford et al., 2006, Herman, 1992, Roth et al., 1997) and its consequences in relational disconnectedness (Dorahy et al., 2009). Growing interest in complex PTSD requires greater scrutinization of not only the components which are proposed to characterize the condition but the aspects which contribute to relational problems. Pelcovitz et al. (1997) operationally defined complex PTSD (Herman, 1992) under the term Disorders of Extreme Stress Not Otherwise Specified (DESNOS), identifying six psychobiological systems where disruptions were primarily evident. These pertained to alterations in affect regulation, attention/consciousness (i.e., dissociation), self-perception, relationships with others, somatic functioning, and meaning. The self-conscious emotions of shame and guilt are affective states central to alterations in self-perception in complex PTSD (Boon et al., 2011, Ford et al., 2006). Tracy and Robins (2007) argue that self-conscious emotions impinge primarily on social functioning. Shame especially can have a negative impact on relating to others (Tangney, 1996). Dissociation can also have a catastrophic impact on relational functioning (Lyons-Ruth, 2003). The current study assessed the impact of shame, guilt and dissociation on relationship functioning in those with chronic and/or complex PTSD. Thus, it attempted to examine the dynamic interplay between 3 aspects of the DESNOS construct: alterations in (1) attention/consciousness (i.e., dissociation), (2) self perception (shame and guilt) and (3) relationships with others. Due to the recent clinical, theoretical and empirical scrutiny of the relationship between dissociation and complex PTSD (e.g., Van der Hart et al., 2005), the present paper also examined the association between these two constructs.
While guilt is often associated with actions or action failures during and after a traumatic event, shame reflects how the individual feels following appraisals of self during or after a traumatic event (Lee et al., 2001). Wilson et al (2006) argue that “states of posttraumatic shame and guilt form the pathological nucleus of simple and complex PTSD” (p. 124, see also Herman, 2011). In individuals experiencing trauma that has a strong relational component, shame is a particularly salient peritraumatic and posttraumatic affect (Budden, 2009, Dorahy, 2010, Dorahy and Clearwater, 2012, Harvey et al., 2012, Stewart and Dadson, Nov, 2011), and is associated with prolonged clinical problems (e.g., Dyer et al., 2009, Feiring and Taska, 2005). For example, in victims of violence, feeling shame regarding the event itself or the person’s own response to it, independently predicted PTSD symptoms at 1 month and 6 months (Andrews et al., 2000).
Emphasising the central affective role of shame, Herman (2011) proposed that PTSD resulting from repetitive victimization at the hands of another can be conceptualized as both an anxiety disorder and a shame disorder. Threats of violence or violence itself evoke fear, while degradation and boundary violation at the hands of another, as well as social isolation evoke shame (Herman, 2011). Chronically traumatized individuals feel shame not only for what has happened to them, but for who they are (Boon et al., 2011, Dorahy and Clearwater, 2012, Talbot, 1996). Shame and guilt may coexist (Wilson et al., 2006) or guilt may give way to shame. For example, in cases where repair is not possible (De Hooge et al., 2010), social avoidance, crippling self-imposed emotional torment and erosion of self worth may follow. Such degradation of the self may lead to feelings of inferiority, weakness and social inadequacy, central to the affect of shame.
Kubany et al. (1995) found a significant relationship between event-related guilt and severity of PTSD symptoms in both combat veterans and women exposed to domestic violence. Yet, when the impact of shame and guilt on PTSD symptoms are examined together, shame typically emerges as the strongest predictor (e.g., Street and Arias, 2001). In a sample of 107 former prisoners of war, Leskela et al (2002) found that shame-proneness but not guilt-proneness was related to severity of PTSD symptoms. Once the effects of shame were statistically removed, guilt showed a negative relationship with PTSD symptoms. This suggests that shame rather than guilt is central to the pathognomonic outcome of relational trauma.
Gruenewald et al (2007) contend that shame and guilt are by and large social emotions. Shame signals threat to the social self (e.g., Budden, 2009, Gilbert and McGuire, 1998) and guilt signals threat to relationships. Shame by its nature is a relational affect, as it is intimately linked to how an individual perceives their self, using the real or imagined perspective of internal or external others as a vantage point (Harder and Lewis, 1987, Wilson et al., 2006). Guilt elicits attempts at reparation following relationship breaches. Shame often leads to relational avoidance and guilt to relational repair. In light of the social functions of shame and guilt, their presence may underlie the devastating impact complex PTSD has on maintaining or forming familial and social relationships (e.g., Kim et al., 2009).
Nathanson (1992) has noted 4 behavioral responses to shame, which form the ‘compass of shame’ and have relational implications. When shame is experienced an individual may respond with social/interpersonal avoidance or withdrawal. Alternatively, they may try to defend against the feeling by attacking themselves or attacking another. The clinical applications of the compass of shame have been outlined in severely traumatised, dissociative patients (Kluft, 2007). However, little research has examined the compass of shame in traumatized adults and its association to relational difficulties.
Recent work suggests that dissociation is a central construct in the etiology, maintenance, organization and treatment of complex PTSD (e.g., Chu, 2011, Ford, 2009, Steele et al., 2005). Zucker et al. (2006) found higher dissociation scores in those with complex PTSD compared to those with solely PTSD. Yet, it remains unclear to what degree dissociation differentiates those with more Complex PTSD symptoms, or can differentiate those with more severe self-conscious emotions, like shame and guilt.
Due to the disruption to an integrated sense of self, dissociation is another psychological experience within the complex PTSD constellation of symptoms that may have a devastating effect on relational functioning. Dissociation has historically been understood as an intrapsychic process where an individual experiences alterations in identity, cognition, and/or awareness (e.g., Cardeña and Carlson, 2011, Carlson and Putnam, 1993, Lanius et al., 2010, Van der Hart and Dorahy, 2009). However, more recently an understanding of the link between dissociation and emotional relationships has started to develop. This work has its impetus in the study of infant attachment and how the disorganized type, often associated with abusive or neglectful parenting, can lead to dissociative difficulties (Harari et al., 2007, Ogawa et al., 1997). In a situation where the child is not nurtured and attended to, they can sever emotional links with the caregiver, by becoming deeply absorbed in their own experience and disconnected and dissociated from the caregiver. In situations where fear is present (e.g., about to be hit by parent), dissociative freeze responses with associated silence can signal an attempt to become disconnected from the fearful stimulus (e.g., abusive parent). When an individual is experiencing a dissociative episode, such as feeling detached from their body, it has a significant impact on their ability to stay emotionally present in that moment to another person (Lyons-Ruth, 2003). As Lyons-Ruth (2008) notes, dissociation is an intrapsychic process and also an interpersonal phenomena (way of relating to others). Dissociation therefore reflects fragmentation of a coherent relational self (Lyons-Ruth, 2008). Thus, dissociation can have a considerable effect on the ability to sustain emotional relationships.
The current study first aimed to examine the centrality of dissociation to complex PTSD symptom severity, including shame and guilt. In line with the belief that dissociation is a key symptom cluster and organizational construct in complex PTSD (e.g., Van der Hart et al., 2005, Van der Hart et al., 2006), dissociation was predicted to differentiate those with high and low complex PTSD symptoms, including shame and guilt. Second, the study aimed to more thoroughly investigate the impact of shame, guilt and dissociation on relationship functioning in those with chronic and complex PTSD. Research has typically shown a relationship between dissociation, shame and guilt (e.g., Budden, 2009, Dorahy, 2010, Dorahy and Hanna, 2012, Dutra et al., 2008, Irwin, 2008, Talbot et al., 2004). Yet, to date few studies have examined the contribution of shame, guilt and dissociation to relational difficulties in chronic and complex PTSD. In one study of these populations, dissociation and lifetime shame, but not guilt, were significant predictors of relational disconnectedness (Dorahy, 2010). Dissociation was found to make a greater contribution than shame. However, this study was methodologically limited by single item measures of shame, guilt and dissociation, and a 3 item measure of relational disconnectedness. Following this pilot work, it was predicted that shame and dissociation, but not guilt, would be related to relationship difficulties.
Section snippets
Participants
All individuals in treatment at a statutory service in Belfast dedicated to psychosocial interventions for individuals affected by the Northern Irish conflict were invited to take part in the study. The service caters for people suffering the direct psychological effects of exposure to the conflict (e.g., family member killed, personally attacked, engaged in violence towards another) and treats both civilians and those involved in the armed struggle. Of the 154 invited to take part, 65
Variable means and intercorrelations
The means and standard deviations for Complex PTSD severity, dissociation severity; trait shame and guilt; shame coping style/response; state shame, guilt, and pride; and negative attitudes and feelings to intimate relationships are in Table 1. Table 2 contains the intercorrelations between the variables.
Complex PTSD and dissociation
Sixty-two (95%) of the 65 participants scored above cut-off (≥11) on the SRC, indicating they had clinically “High” levels of Complex PTSD (Ford et al., 2007). Moreover, 27 participants (42%)
Discussion
The current study examined the centrality of dissociation in chronic and complex PTSD by determining whether it would differentiate Complex PTSD symptom severity, including those associated with shame and guilt. In addition, the study also tested whether dissociation, shame and guilt significantly impacted on attitudes to, feelings towards, and difficulties in, interpersonal relationships. Consistent with the first hypothesis, dissociation differentiated individuals with high and low complex
Role of funding source
No funding was obtained for this study.
Conflict of interest
The authors have no conflict of interest.
Acknowledgment
The authors would like to thank Suzanne Muhtadi and Vanessa Baird for assistance with data handling.
References (66)
The role of shame in posttraumatic stress disorder: a proposal for a socio-emotional model for DSM-V
Social Science & Medicine
(2009)- et al.
Complex PTSD, interpersonal trauma and relational consequences: findings from a treatment-receiving Northern Irish sample
Journal of affective disorders
(2009) - et al.
Psychological trauma and PTSD symptoms as predictors of substance dependence treatment outcome
Behaviour Research and Therapy
(2007) - et al.
Childhood abuse and current interpersonal conflict: the role of shame
Child Abuse and Neglect
(2009) Conceptual & methodological issues in the assessment of shame and guilt
Behaviour Research and Therapy
(1996)- et al.
The measurement of dissociation in normal and clinical populations: meta-analytic validation of the dissociative experiences scale (DES)
Clinical Psychology Review
(1996) - et al.
Predicting PTSD symptoms in victims of violent crime: the role of shame, anger and childhood abuse
Journal of Abnormal Psychology
(2000) - et al.
Coping with Trauma-related Dissociation: Skills Training for Patients and Therapists
(2011) Trauma Assessment: A Clinician’s Guide
(1997)- et al.
Acute stress disorder revisited
Annual Review Of Clinical Psychology
(2011)
An update on the dissociative experiences scale
Dissociation
Rebuilding Shattered Lives: Treating Complex Post-traumatic and Dissociative Disorders
Evaluation of the evidence for the trauma and fantasy models of dissociation
PsychologyBulletin
Restore and protect motivations following shame
Cognitive Emotion
The impact of dissociation, shame, and guilt on interpersonal relationships in chronically traumatized individuals: a pilot study
Journal of Traumatic Stress
Shame and guilt in men exposed to childhood sexual abuse: a qualitative investigation
Journal of Child Sexual Abuse
Shame, intimacy and self-definition: an assessment of the emotional foundation and intimate relationship consequences of an introjective personality orientation
Journal of Nervous and Mental Disease
The relational context of dissociative phenomena
Core schemas and suicidality in a chronically traumatized population
Journal of Nervous and Mental Disease
Anger, aggression and self-harm in PTSD and complex PTSD
Journal of Clinical Child Psychology
Investigating the compass of shame: the development of the compass of shame scale
Social Behavior and Personality
The persistence of shame following sexual abuse: a longitudinal look at risk and recovery
Child Maltreatment
Disorders of extreme stress following warzone military trauma: associated features of post-traumatic stress disorder (PTSD) or comorbid but distinct syndromes
Journal of Consulting and Clinical Psychology
Disorders of extreme stress (DESNOS) symptoms are associated with type and severity of interpersonal trauma exposure in a sample of healthy young women
Journal of Interpersonal Violence
Shame, status and social role. The psychobiological continuum from monkeys to humans
A social function for self-conscious emotions: the social self preservation theory
Shame
Attachment, disorganisation and dissociation
Shame and guilt assessment, and relationships of shame- and guilt-proneness to psychopathology
The assessment of shame and guilt
Childhood psychological maltreatment and perception of self, others, and relationships: a phenomenological exploration
Journal of Emoticons Psychology
A generic measure of relationship satisfaction
Journal of Marriage and Family
Cited by (108)
Onno van der Hart & Olivier PiedFort-Marin's “amnesia and hypermnesia as a paradigm of non-realization in trauma-related dissociation: Pierre Janet's Case of Irene”: A review and commentary
2024, European Journal of Trauma and DissociationEvidence for the Impact of Stress and Trauma on Sexual Function in Women: Review and Clinical Recommendations
2024, Obstetrics and Gynecology Clinics of North AmericaCritical thinking as cooperation and its relation to mental health and social welfare
2023, New Ideas in PsychologyTracing the paths: a systematic review of mediators of complex trauma and complex post-traumatic stress disorder
2024, Frontiers in Psychiatry