Research report
Complex trauma and intimate relationships: The impact of shame, guilt and dissociation

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Abstract

Background

This study examined dissociation, shame, guilt and intimate relationship difficulties in those with chronic and complex PTSD. Little is known about how these symptom clusters interplay within the complex PTSD constellation. Dissociation was examined as a principle organizing construct within complex PTSD. In addition, the impact of shame, guilt and dissociation on relationship difficulties was explored.

Methods

Sixty five treatment-receiving adults attending a Northern Irish service for conflict-related trauma were assessed on measures of dissociation, state and trait shame, behavioral responses to shame, state and trait guilt, complex PTSD symptom severity and relationship difficulties.

Results

Ninety five percent (n=62) of participants scored above cut-off for complex PTSD. Those with clinical levels of dissociation (n=27) were significantly higher on complex PTSD symptom severity, state and trait shame, state guilt, withdrawal in response to shame and relationship preoccupation than subclinical dissociators (n=38). Dissociation and state and trait shame predicted complex PTSD. Fear of relationships was predicted by dissociation, complex PTSD and avoidance in response to shame, while complex PTSD predicted relationship anxiety and relationship depression.

Limitations

The study was limited to a relatively homogeneous sample of individuals with chronic and complex PTSD drawn from a single service.

Conclusions

Complex PTSD has significant consequences for intimate relationships, and dissociation makes an independent contribution to these difficulties. Dissociation also has an organizing effect on complex PTSD symptoms.

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.

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