Shame and guilt in adolescents exposed to violence and sexual abuse Den 8. nordiske konference om børnemishandling og omsorgssvigt NFBO, Nuuk 2014 Siri Thoresen, Mia Myhre & Ole Kristian Hjemdal

Background: Initiative in «Turning Point», the Government Action Plan against Domestic Violence Aim of main study: Prevalence of violence and abuse in Norway Relations between victims and perpetrators Consequences for health

Background for this presentation: Previous studies have found trauma-related shame to be associated with mental health. The importance of trauma- related guilt for mental health is more debated. Aim of this presentation: Investigate how shame and guilt relate to various types of violence in adolescence Investigate how violence, shame and guilt relate to mental health

Procedure A random sample (16-17 year-olds) was drawn from the General Population Registry of Norway Postal information letter Contacted by telephone Response Rate: 62 % (of those reached by phone) N = 2062

What is violence? WHO: Physical violence Sexual violence Psychological violence Neglect

WHO: We measured: Physical violencePhysical violence from caretaker and parental IPV Sexual violenceSexual abuse before age 13, forcible rape and intoxicated rape Psychological violencePsychological violence from caretaker NeglectEmotional neglect

Strategy for measuring violence: Telephone interview structure adapted after national studies in the USA (Kilpatrick et al, 2004) Expanded to include a detailed assessment of childhood violence Affirmative answers followed by supplementary question Behaviorally specific questions, sample item rape: « “Has anyone ever forced you into intercourse by use of physical force or by threatening to hurt you or someone close to you?”

Shame and guilt Both are painful and self-evaluating emotions Both are social in nature, and serve important regulative functions Highly related, but distinguishable Shame: global, negative evaluation of self Related to hiding behaviour and perceived loss of value in the eyes of others Guilt: specific, negative evaluation of own behaviour Related to reparation behaviour and self blame (Tangney & Dearing, 2002; Gilbert, 1997)

Shame “a painful affect, often associated with perceptions that one has personal attributes (e.g. body shape, size or textures); personality characteristics (e.g. boring, unintelligent or dishonest) or has engaged in behaviors (e.g. lying, stealing) that others will find unattractive and result in rejection or some kind of put-down” Gilbert, Evolutionary perspective, social perspective

Guilt “an unpleasant feeling with an accompanying belief that one should have thought, felt or acted differently” Kubany, Heynes et al, 1996

Existing measures of shame and guilt were adapted to clinical samples with an acknowledged trauma. We developed a new scale of shame and guilt, inspired by -the Experience of Shame Scale (Andrews, Qian, & Valentine, 2002) -the Others As Shamers Scale (Goss, Gilbert, & Allan, 1994) -the Trauma-Related Guilt Inventory (Kubany et al., 1996)Andrews, Qian, & Valentine, 2002Goss, Gilbert, & Allan, 1994Kubany et al., 1996

TRG: Trauma-related Guilt and Shame Scale: A new measure Guilt (Alpha = 0.84) Shame (Alpha = 0.85) Have you blamed yourself for any part of what happened? Have you been worried about what people might think of you after what happened? Have you been bothered by thoughts that you should have done something differently to prevent what happened? Have you tried to conceal what happened, or any part of it? Have you been bothered by thoughts that you should have done something differently while it was happening? Have you felt ashamed about any part of what happened? Have you felt that you did anything wrong? Have you looked down on yourself after what happened? Have you experienced any feelings of guilt about any part of what happened?

Measures: Mental health Anxiety and depression: Hopkins symptom checklist (HSCL-10, alpha = 0.89) Posttraumatic stress reactions: PTSD check list (PCL-6, alpha = 0.81)

Results

Exposure to violence: Sexual abuse ExposureTotal % Girls % Boys % Sexual abuse <131,31,90,8 Forcible rape1,83,50,2 Intoxicated rape1,52,50,6 Any of the above4,16,71,5 Other SA7,311,73,0

Exposure to violence: Physical violence ExposureTotal % Girls % Boys % Severe physical violence from caretaker 1,82,31,3 Parental IPV3,34,91,7 Any of the above4,46,22,7 Mild physical violence from caretaker 9,49,69,3

Exposure to violence: Psychological violence/neglect ExposureTotal % Girls % Boys % Psychological violence from caretaker 6,610,03,3 Emotional neglect4,34,44,2 Any of the above9,412,36,7

Guilt («A bit» and «A lot» collapsed) ExposureBlamed yourself Should have prev- ented Should acted differ- ently Did some- thing wrong Felt guilty about it Sexual abuse <1352%**78%**70%**56%**63%** Forcible rape54%**83%**71%**53%**52%** Intoxicated rape66%**90%**71%**58%**61%** Physical violence from caretaker46%**60%**52%**49%**54%** Parental IPV39%**49%*45%*37%49%** Psych violence from caretaker42%**61%**52%**42%**43%** Emotional neglect26%52%**39%*43%**39%*

Shame («A bit» and «A lot» collapsed) ExposureWorry what others think of you Tried to conceal it Felt ashamed about it Looked down on yourself Sexual abuse <1359%**82%**78%**59%** Forcible rape63%**83%**66%**80%** Intoxicated rape77%**68%**81%**84%** Physical violence from caretaker49%**74%**49%**51%** Parental IPV40%*51%**33%40%** Psych violence from caretaker54%**58%**44%**50%** Emotional neglect45%**56%**45%**49%**

Guilt and shame and burden of violence No of exposure categories* Guilt Mean (SD) Shame Mean (SD) (0.42)0.24 (0.42) (0.54)0.59 (0.59) (0.59)0.72 (0.60) 3 or more1.01 (0.67)1.24 (0.68) * 0-3 or more of: SO before 13, forcible rape, intoxicated rape, physical violence from caretaker, parental IPV, psychological violence from caretaker, and emotional neglect Both guilt and shame were significantly associated with number of exposure categories: No of exposure categories and guilt: r = 0.33, p < No of exposure categories and shame: r = 0.42, p < 0.001

Anxiety and depression (HSCL-10, N = 1129) ExposureUnadjustedAdjusted B95% CIB Sexual abuse ** ** Physical violence ** * Psych vio/emo neglect ** **

Anxiety and depression (HSCL-10, N = 1129) ExposureUnadjustedAdjusted B95% CIB Sexual abuse Physical violence Psych vio/emo neglect Guilt ** ** Shame ** **

Anxiety and depression (HSCL-10, N = 1129) ExposureUnadjustedAdjusted* B95% CIB Sexual abuse ** Physical violence ** Psych vio/emo neglect ** ** Guilt ** ** Shame ** ** *Additionally adjusted for gender

ExposureUnadjustedAdjusted B95% CIB Sexual abuse ** ** Physical violence ** ** Psych vio/emo neglect ** ** Post-traumatic stress reactions (PCL-6, N = 1129)

ExposureUnadjustedAdjusted B95% CIB Sexual abuse Physical violence Psych vio/emo neglect Guilt ** ** Shame ** **

ExposureUnadjustedAdjusted* B95% CIB Sexual abuse ** Physical violence ** * Psych vio/emo neglect ** ** Guilt ** ** Shame ** ** *Additionally adjusted for gender Post-traumatic stress reactions (PCL-6, N = 1129 N = 1129)

Conclusions Violence-exposed adolescents feel shame and guilt about what happened Shame and guilt were highest for sexual abuse, but were also very prevalent for physical violence, psychological violence and neglect. The more violence, the more shame and guilt

Conclusions Both shame and guilt were associated with mental health problems in violence-exposed adolescents Associations were practically the same for anxiety/depression and post-traumatic stress reactions, indicating a general effect on mental health Shame and guilt may represent two separate pathways to mental health problems

Conclusions Shame is thought to elicit hiding behavior Guilt is thought to elicit rumination and self blame Neither self blame nor hiding behaviour would likely promote help-seeking. Outreach and systematic screening is necessary: We have to ask!

Some limitations: Cross-sectional study Non-response – selection Underreporting? Some strengths: Broad assessment of violence exposure Behavioural specific and direct way of questioning High-quality measures

A full report on adolescents soon to come (in Norwegian)

Thanks for listening!

Vold i barndom MennKvinner Mindre alvorlig vold fra foresatte (lugget/kløpet, ristet/dyttet voldsomt/slo m flat hånd) 33 %28 % Alvorlig vold fra foresatte (Slo m/knyttneve eller hard gjenstand, sparket, banket opp, angrepet fysisk på andre måter) 5 % Vitne til vold mellom foresatte (slo flat hånd/ knyttneve/hard gjenstand, sparket, kvelertak, angrep fysisk andre måter) 10 % Psykologisk vold (foreldre/foresatte gjentatte ganger gjorde narr av deg, ydmyket deg, ignorerte deg, fortalte deg at du ikke fikk til noen ting) 11 %15 % Følelsesmessig omsorgssvikt (ikke føle seg elsket av foresatte) 9 %10 % Seksuelle overgrep før 13 år (Lurt, lokket, tvunget eller truet til seksuelle handlinger med en minst 5 år eldre person) 4 %10 % Voldtekt før 18 år (Tvang til samleie, oralsex, analsex eller penetrasjon med objekter v/bruk av makt eller trusler om å skade) 1 %5 %

Eksempel (menn og kvinner sammenslått) Vitne til vold mellom foresatte Psykologisk vold fra foresatte Alvorlig vold fra foresatte Utsatt Ikke utsatt 47 % 7 % 65 % 10 % 13 % utsatt for seksuelle overgrep før 13 år, voldtekt og/eller alvorlig vold fra foresatte i barndom. Ikke flere i hvert årskull enn at det burde være mulig å finne dem og gi dem hjelp. Vold i barndom: Mange opplever flere former for vold

Alder første gang Fysisk vold fra foresatte: Barnehage eller småskole Seksuelle overgrep før 13 år: (2 / 3 før 10 år) Barneskole/ungdomsskole Voldtekt før 18 år: (2 / 3 før 16 år) Ungdomsskole/videregående

Færre nå enn før? Færre utsatt for vold fra foresatte - særlig mindre alvorlig vold (fra 1 av 3 til 1 av 5) Ingen endring - voldtekt og andre seksuelle overgrep før 18 år

Skam og skyld (hos de under 25 år) Antall vold/ overgrep som barn Prøvd å skjule det Skammet deg over det Sett ned på deg selv Bebrei- det deg selv Følt du gjorde noe galt eller fler

Voldsutsatte barn bærer med seg en risiko for å bli utsatt for nye overgrep i voksen alder Forhold mellom utsatthet i barndom og i voksen alder. Kvinner Utsatthet i barndomVoldtekt voksenGrov vold voksen Seksuell kontakt før 13 år Utsatt Ikke utsatt 27 % 5 % 33 % 10 % Grov vold fra foresatte i barndom Utsatt Ikke utsatt 19 % 5 % 29 % 10 %

Psykisk helse Blir man sterk av motgang?

Antall vold/overgreps- erfaringer som barn Antall vold/overgreps-kategorier som voksen 0 12 eller fler 05 %11 %15 % eller fler Angst/depresjon: Andel over kutteskåre (11% totalt)

Antall vold/overgreps- erfaringer som barn Antall vold/overgreps-kategorier som voksen 0 12 eller fler 05 %11 %15 % 113 %31 %33 % 220 %33 %47 % 3 eller fler40 %54 %59 % Angst/depresjon: Andel over kutteskåre (11% totalt)

Antall vold/overgreps- erfaringer som barn Antall vold/overgreps-kategorier som voksen 0 12 eller fler 05 %11 %15 % 113 %31 %33 % 220 %33 %47 % 3 eller fler40 %54 %59 % Angst/depresjon: Andel over kutteskåre (11% totalt)

Psykisk helse Av skade blir man ikke sterk, men skadet. Vold i barndom bidrar vesentlig til psykiske helseproblemer som voksen. Vold i barndom skaper større sårbarhet for vanskeligheter som voksen. Tidlig intervensjon!

Konklusjoner Vold og overgrep mot barn er ikke uvanlig. Det er likevel ikke fler enn at vi burde kunne nå ut til dem. Vold og overgrep i barndom er knyttet til - risiko for vold og overgrep i voksen alder - psykiske helseproblemer. Vold og overgrep i barndom er sterkt knyttet til skam og skyld. Det er ikke rimelig å forvente at de selv vil søke hjelp. Vi må spørre dem.

Takk for at du hørte på!

Voldtekt: Har noen noen gang tvunget deg til å ha samleie ved å bruke fysisk makt eller ved å true med å skade deg eller noen som står deg nær? Tilsvarende spørsmål om -oralsex -analsex -fingre eller objekter inn i vagina eller anus

Forebygging Forekomst av vold mot barn: Intervensjoner på samfunnsnivå: Lover, rettigheter, holdninger, synliggjøring, levestandard, arbeidsledighet, kvinnesyn (Finkelhor, 2006) Et bedre liv for utsatte barn: Individuelle intervensjoner Skalering av hjelpetiltak Økt kompetanse Tørre å spørre

The role of shame and guilt Shame should figure more prominently in understandings of the emotional underpinnings of depressive symptoms (Sangmoon et al, 2011) Shame and guilt have been found in survivors of a variety of potentially traumatic events (Andrews, Brewin, Rose, & Kirk, 2000; Kubany et al., 1996; Street & Arias, 2001). The two emotions differ in several ways, such as whether the focus of self-evaluation is the global self (shame) or a certain behavior (guilt; Tangney & Dearing, 2002), or whether hiding behavior (shame) or reparation behavior (guilt) is elicited (Gilbert, 1997). They are, however, both self-conscious emotions (Lewis, 2008; Tangney & Dearing 2002), typically experienced in an interpersonal context (Tangney & Dearing, 2002). Shame, and to a lesser extent, guilt, are associated with mental health problems such as depression (Kim et al., 2011), social anxiety (Gilbert, 2000), and posttraumatic stress disorder (PTSD; Kubany, 1994; Lee, Scragg, & Turner, 2001; Leskela, Dieperink, & Thuras, 2002). Shame and guilt may contribute to PTSD through the individual’s evaluation of meaning of the event (e.g. shame through loss of status or social attractiveness, and guilt through responsibility or hindsight bias; Lee et al., 2001). Other explanations may be negative guilt cognitions causing memories to be more painful and more resistant to extinction (Kubany & Manke, 1995) and shame interacting with fear and anger (Budden, 2009). Explanations for the occurrence of shame and guilt after trauma include stigmatization and secrecy (Finkelhor & Browne, 1985), and victims taking the blame or being blamed by others for what happened (Brewin, 2003; Campbell & Lewandowski, 1997).

When selecting measurements of trauma-related shame and guilt, we reviewed several instruments available. Very few were fit to measure these emotions after trauma in a way that was possible on the phone. Two instruments could be used this way; the Trauma-Related Guilt Inventory (Kubany et al., 1996) and an instrument measuring shame inspired by Kubany’s work, created by researchers at Modum Bad hospital. Both of these instruments were deemed more fit in a setting where respondent have an acknowledged trauma (e.g. with a clinical sample seeking treatment for their trauma experience) than in a population sample. Thus, we found it most appropriate to create a scale for this survey. We based our scale on the Experience of Shame Scale (Andrews, Qian, & Valentine, 2002), the Others As Shamers Scale (Goss, Gilbert, & Allan, 1994) and the Trauma- Related Guilt Inventory (Kubany et al., 1996). The scale had a Cronbach’s alpha of X.Kubany et al., 1996Andrews, Qian, & Valentine, 2002Goss, Gilbert, & Allan, 1994Kubany et al., 1996