Content uploaded by Tuva Oktedalen
Author content
All content in this area was uploaded by Tuva Oktedalen on Dec 06, 2015
Content may be subject to copyright.
The Trauma Related Shame Inventory: Measuring
Trauma-Related Shame Among Patients with PTSD
Tuva Øktedalen &Knut Arne Hagtvet &Asle Hoffart &
Tomas Formo Langkaas &Mervin Smucker
#Springer Science+Business Media New York 2014
Abstract This article proposes a new measurement instru-
ment of trauma-related shame. The purpose of this study is to
investigate the psychometric properties of the scores derived
from the Trauma Related Shame Inventory (TRSI) by means
of generalizability theory (G-theory). The psychometric anal-
yses are based on a sample of 50 patients in treatment for Post-
traumatic Stress Disorder (PTSD). The results provided
supporting construct validity evidence for the interpretation
of TRSI as a homogeneous construct. The 24-item version of
internal and external referenced shame yielded generalizabil-
ity and dependability coefficients of .874 and .868, respec-
tively. The distinction between shame and guilt was supported
by a high generalizability coefficient of .812 for the difference
scores between TRSI and guilt cognition scale. Further valid-
ity evidence was provided by a positive relationship between
TRSI and a) self-judgment subscale in Self-Compassion Scale
(SCS; Neff Self and Identity 2:(3), 223–250, 2003)andb)
Beck Depression Inventory (Beck Steer and Brown 1996a)
when controlled for guilt. The results of the present study
provided promising support for using the 24-item version of
TRSI in both clinical research and practice.
Keywords PTSD .Trauma related shame .Generalizability
theory .Multivariate generalizability analysis
Introduction
To date, the concepts of posttraumatic shame have received
little empirical investigation in the field of traumatology, with
a few notable exceptions (Beck et al. 2011; Matos and Pinto-
Gouveia 2010; Resick et al. 2008;HarmanandLee2010;
Leskela et al. 2002; Platt and Freyd 2012;Sembetal.2011;
Street and Arias 2001). In particular, definitions of posttrau-
matic stress disorder (PTSD) emphasize fear, but newer theo-
ries and increasing evidence in the recent years suggest that
non-fear emotions, such as shame, may be important features
of PTSD (Holmes et al. 2005; Grunert et al. 2003;Grunert
et al. 2007; Smucker et al. 2003;Becketal.2011;Resicketal.
2008; Harman and Lee 2010;Sembetal.2011). Recent
theoretical contributions have specified the role of shame in
maintaining symptoms of PTSD (Harman and Lee 2010;
Ehlers and Clark 2000). Both trauma-related shame and guilt
cognitions elicit aversive emotions and can function as re-
minders of trauma memories (Ehlers and Clark 2000). The
persistent self-criticism associated with shame represent a
threat to the self and can contribute to the maintenance of
PTSD symptoms by reinforcing the sense of ongoing threat
(Ehlers and Clark 2000). Shame appraisals lead to shame-
charged intrusions, great distress, with avoidance and thought
suppression (Harman and Lee 2010; Lee et al. 2001; Lee
2005), and consequently strengthen the relationship between
shame and intrusions. In addition, the inclusion of shame and
guilt in the criteria for PTSD in the newly released DSM–V
have profound consequences for the conceptualization, as-
sessment and treatment of PTSD.
Patients in clinical settings are sometimes reluctant to dis-
close feelings of shame out of fear from being exposed and
rejected (Macdonald and Morley 2001). Unfortunately, failure
to identify shame in patients can be disruptive to treatment,
(e.g., lead to treatment stagnation, prolonged treatment, or
reduced treatment outcome) (Arntz et al. 2007;Brewinetal.
T. Øktedalen (*):A. Hoffart :T. F. Langkaas
Department of Psychology, University of Oslo
& Research Institute at Modum Bad, Gordon Johnsens vei,
3370 Vikersund, Norway
e-mail: tuva.oktedalen@psykologi.uio.no
K. A. Hagtvet
Department of Psychology, University of Oslo,
Forskningsveien 3A, 0137 Oslo, Norway
M. Smucker
IRRT Zentrum, Hamburg, Germany
J Psychopathol Behav Assess
DOI 10.1007/s10862-014-9422-5
1996; Resick and Schnicke 1993). Some studies indicate that
shame and guilt are both associated with reduced outcome of
prolonged exposure, in which imagery exposure (IE) is a
central component. These studies also indicate that the treat-
ment model imagery rescripting (IR) is effective and relevant
for PTSD patients with complex emotion profiles (Arntz et al.
2007; Grunert et al. 2003; Grunert et al. 2007). Cognitive
processing therapy (CPT; Resick and Schnicke 1992) is a type
of cognitive behavioral therapy that also has been shown to be
effective in the treatment of a variety of emotional reactions in
PTSD. Thus, a shame inventory could be useful in tailoring
existing treatments to effectively target shame for patients
with more complex emotional profiles. Consequently, an in-
strument assessing shame in the context of trauma is needed
for clinical evaluation as well research purposes. Accordingly,
the goal of the present study is to investigate the psychometric
properties of a newly created assessment of shame in the
context of trauma.
Shame Versus Guilt
Frequently, shame and guilt are used as equivalent terms, but
several writers have distinguished them with reference to
different emotional experiences (Lindsay-Hartz 1984;
Tangney and Dearing 2003; Tangney et al. 1996). Most shame
theorists agree that shame involves negative evaluations of the
entire self (Kubany and Watson 2003). Theoretically, shame
involves painful self-scrutiny and self-condemnation, along
with feelings of worthlessness and powerlessness, and
coupled with a behavioral tendency to hide, disappear, or
withdraw out of fear from condemnation and rejection of
significant others (Lindsay-Hartz 1984; Tangney 1991;
Greenberg and Paivio 1997;Lewis1995;Nathanson1987;
Stone 1992; Tangney 1991;Tomkins1987). It is further
postulated that shame is associated with negative biases when
judging others’evaluation of the self, and involves a desire to
conceal one’s own perceived deficiencies from the evaluation
of others (Lewis 1971; Tangney et al. 1996; Wicker et al.
1983). Accordingly, the cognitive (self-condemnation), affec-
tive and behavioral (hiding and withdrawing behavior) com-
ponents of shame constitute the definition of shame and were
included in the measurement design of the Trauma-related
Shame Inventory (TRSI) to be described below.
Consequently, shame is characterized as a more painful emo-
tion in which the entire self, and not just the behavior, is
negatively evaluated (Lewis 1995; Tangney and Dearing
2003). In contrast, guilt involves negative evaluations of spe-
cific actions or behaviors and motivates individuals to attempt
reparative actions. (Kubany and Manke 1995; Lewis 1995;
Nathanson 1987; Tangney 1991; Tangney et al. 1996).
However, researchers have generally failed in prior attempts
to distinguish guilt and shame and to provide precise
operational definitions of shame (Kubany and Watson
2003). The gap between the clinical interest in shame and
guilt, and the empirical focus on these self-evaluated emotions
in treatment studies has been due largely to difficulties in the
operationalization and distinction of these complex
constructs.
Gilbert (1997) distinguished between external- and internal
shame, in which two reference norms, personal and social,
play different roles in the self-evaluation process. External
shame is related to one’s preoccupation about how others will
appraise and evaluate the self. In external shame the concern is
how one is seen and evaluated by others (e.g., fear of being
scorned, devaluated or ridiculed by other persons). By con-
trast, internal shame relates to one’s preoccupation with self-
devaluations in which one evaluates oneself as flawed, weak,
inadequate and inherently disgusting, which is the very defi-
nition of shame provided by Lewis (1971), Lewis (1995)and
Tangney and Dearing (2003) among others. According to
Gilbert (1997;GilbertandAndrews1998), internal shame
occurs when an individual personalizes the traumatic experi-
ence and views it as confirming evidence of personal failure.
Even though external- and internal shame are assumed to be
highly correlated, Gilbert views them as two separate subcat-
egories of shame. Whether external shame can occur in the
absence of negative self-evaluation, or whether external
shame is a result of one’s negative evaluations of the self,
which constitute internalized shame, remains an empirical
question. In accordance with Gilbert’s theory (Gilbert 1997;
Gilbert and Andrews 1998), external shame, is also assumed to
be part of the shame-ridden individual and related to the affec-
tive and behavioral components of shame. Accordingly,
the affective component of shame and the behavioral
tendency to hide and withdraw are assumed to be im-
portant aspects of both internal- and external shame and
were included in the measurement design of the TRSI.
The categories of internal- and external shame along
with the subcategories of self-condemnation, affective-
and behavioral components of shame are therefore in-
cluded as essential features of the measurement design
of the TRSI.
Condemnation of the self involves a judgmental and
critical stance towards the self (Gilbert and Miles 2000).
Self-Judgment has been linked in prior research both
empirically (Neff 2003; Gilbert and Miles 2000)and
theoretically (Gilbert and Miles 2000)tointernalshame
and depression. According to Orth et al. (2006), nega-
tive emotions like shame in contrast to guilt elicits
rumination which then leads to depression. Prior re-
search indicates that self-criticism is part of the shame
construct (Gilbert and Miles 2000), and a study by
Gilbert and Procter (2006) found that shame was asso-
ciated with low self-compassion, high self-criticism and
low self-esteem.
J Psychopathol Behav Assess
Assessments Used in Research on Trauma-Related Shame
Although, shame has captured the attention of clinical psychol-
ogists for decades, systematic empirical research is scarce
(Beck et al. 2011;Blum2008). The gap between the clinical
interest in shame and the empirical focus on this emotion in
relation to trauma has been due largely to difficulties in the
measurement of the construct (Blum 2008). Independent con-
ceptual analyses of the applied indicators for shame, as sug-
gested in the methodological literature (Cronbach et al. 1972;
Benson and Hagtvet 1996; Messick 1995; Nunnally and
Bernstein 1994;Kane2001), are scarce or absent in assessment
of shame. Part of the problem in the assessment of shame is
defining the domain of indicators for shame as distinguished
from guilt and self-concept. The general approach taken in
measuring shame is to include a number of different but related
indicators of the construct in one scale (Andrews et al. 2002).
The items have no direct reference in the item formulations to
the concrete aspects of the construct under investigation (e.g.,
cognitions, emotional expressions or behavioral indicators of
shame) or to specific contexts (like shame reactions in relation
to trauma). Unfortunately, researchers with contradictory
views on shame tend to design measurement instruments that
reflect their own particular approaches (Andrews et al. 2002;
Blum 2008). As such, the measures of shame vary substantial-
ly in structure and format with different conceptual distinctions
to other emotions and self-concepts. Cook (1989), for exam-
ple, defined internalized shame as an “enduring chronic shame
that has become internalized as part of its identity and which
can be most succinctly characterized as a deep sense of inferi-
ority, inadequacy or deficiency”(p. 9). He suggests that inter-
nalized shame and self-esteem are two sides of the same coin
(Cook 1991). The inclusion of indicators of self-esteem in the
measurement domain of “The Inventory of Internalized
Shame”(ISS; Cook 1989,1993)areunfortunatebecauseit
rules out the possibility of exploring the relationship between
shame and self-esteem, as well as their independent relation-
ship to other psychological concepts (Tangney and Dearing
2003). An assessment of shame that includes items tapping
self-esteem or guilt will result in confounding different con-
structs with potentially different effects on outcome in applied
research.Itisnotuncommontofindshameandguilttobe
differently related to psychological functioning and symptoms
with even opposite direction of the effects (Leskela et al. 2002;
Street and Arias 2001). Using assessments that confound
shame andguiltrun the risk of obtaining negligible correlations
to the variable of interest because these effects have basically
cancelled each other out. Thus, one may erroneously conclude
that these emotions are not relevant to the variable of interest
(Tangney and Dearing 2003). The consistent reports of high
correlations between shame and scales of guilt and self-esteem
across a number of different questionnaires (Cook 1988,1991)
may be an indication that shame often occurs together with
guilt and low self-esteem, or it may reflect methodological
problems.
Several issues persist in considering scales used in present
research on trauma-related shame. The most widely used scale
in research on shame is the Test of Self-Conscious Affect
(TOSCA; Tangney et al. 1989), which represents 15 hypo-
thetical scenarios in real-life situations that may elicit shame
and guilt reactions. There are several problems using scales
with hypothetical situations for shame, especially in clinical
populations. The hypothetical situations represent situations
encountered in every-day life and are not relevant to capture
intense shame reactions in specific domains such as in the
aftermath of traumatic incidents (Beck et al. 2011).
Consequently, the scales lack ecological validity due to non-
existence of possibilities to report actual shame reactions
among PTSD patients. In addition, the hypothetical situations
do not include clinical aspects of shame related to condemna-
tion of ones emotional- and behavioral reactions or coping
ability, which are hypothesized to be important for trauma
related shame (Lee et al. 2001).
Another approach in assessing shame is by asking general
questions of shame reactions as in The Trauma Appraisal
Questionnaire (TAQ; DePrince et al. 2010)andThe
Experience of Shame Scale (EES; Andrews et al. 2002).
Andrews et al. (2002) constructed EES to assess four areas
of characterological shame, and this scale is used in recent
clinical research on trauma-related shame (Harman and Lee
2010;Resicketal.2008). By asking general questions about
shame over personal characteristics, habits, and manner with
other people with no reference to concrete examples of cog-
nitions, emotional expressions or behavioral indicators of
shame in a situational context, the respondents are more
susceptible to their own idiosyncratic understanding of this
abstract and complex concept. This might result in conceptual
ambiguity and diversity in responses. (e.g., one of the items in
the TAQ is formulated “It’sasifmyinsidesaredirty”). In
addition, no instruments available tap important aspects of
shame such as fear of negative consequences of disclosure
like rejection and condemnation from significant others,
which are central components in the definition of shame
(Lewis 1995).
Related to the typical procedures of creating shame scales
referred to above, there is reason to believe that not all features
of shame in a clinical context are represented in the items of
previous instruments. Despite the methodological problems
regarding the available assessments of shame, studies of shame
in relation to trauma relies on the measure The Inventory of
Internalized Shame (Beck et al. 2011; Wong and Cook 1992),
TOSCA (Leskela et al. 2002;StreetandArias2001)andThe
Experience of Shame Scale (Resick et al. 2008;Matosand
Pinto-Gouveia 2010;HarmanandLee2010). Despite the need
for developing assessment of trauma-related shame focusing on
global negative assessment of one’s self in a situational context
J Psychopathol Behav Assess
relevant for traumatized individuals (Beck et al. 2011), there is
no such measure available.
In the currently managed health care environment, there is
growing pressure for clinicians and researchers to use abbre-
viated instruments that measure complex constructs more
quickly than the original full scale versions. A number of
authors have argued for the use of short-form measure in
clinical practice for screening purposes in order to reduce
behavioral-observation time and costs (Donders 1997;
Santor and Coyne 1997). A similar argument could be made
for the use of a short version of the TRSI consisting of 24
items in clinical research and practice.
Aims of the Study
In the present study, the framework of generalizability theory
(G-theory) will be applied to assess psychometric properties of
scores reflecting trauma-related shame in patients with PTSD.
G-theory provides a framework for most accurately estimating
the reliability of scores based on the simultaneous analysis of
multiple sources of error variances and combinations of these
sources of variances (Brennan 2001a,b). G-theory also provides
the opportunity to investigate alternative measurement designs
in order to optimize sufficient number of items that provide
acceptable generalizability and dependability of scores. G-
theory represents a new approach in the measurement of shame,
and is considered to be a relevant statistical framework to
investigate psychometric properties of scores when applying a
measurement design with multiple sources of variance (Brennan
2010). The purpose of this study was to assess 1) the internal
structure of a newly-developed self report measure of trauma-
related shame by means of G-theory when taking into account
all its identifiable sources of variation and covariation in the
present measurement design, 2) alternative measurement de-
signs in order to find the lowest number of items that provide
acceptable generalizability and dependability of scores without
narrowing the measurement domain of trauma-related shame, 3)
the differential construct validity between shame and guilt, and
4) the relationship between TRSI and a) depression, and b)
internal shame measured by the subscale “self-judgment”in
the Self-Compassion Scale (SCS; Neff 2003). Consistent with
the theoretical considerations presented earlier, we expect the
subcategories of self-condemnation, behavioral- and affective
components to be highly correlated. In light of the theoretical
considerations and empirical results presented earlier, we also
anticipate that high scores on the TRSI would be related to high
scores on both self-judgment and depression. By taking into
account the sharp conceptual distinction between shame and
guilt in the creation of the TRSI, we expect that scores of the
TRSI represent shame in relation to trauma without confounding
shame and guilt.
Method
Participants
The sample consisted of 68 patients diagnosed with PTSD
from all parts of Norway seeking treatment for this disorder at
a psychiatric hospital in Norway. Seventy-one patients were
found eligible for treatment at the assessment stay and admit-
ted to treatment from December 2008 to November 2010. At
admission, all these 71 patients were found to meet research
criteria, but 3 of them declined research participation. A
standardized clinical interview was conducted by two psy-
chologists using Posttraumatic Symptom Scale Interview
(PSS-I; Foa et al. 1993). The ratings of the psychologists
conducting the standardized clinical interviews were checked
for inter-rater agreement. Inter-rater agreement for the contin-
uous items constituting PSS-I was evaluated by means of ICC
(3, 1) (Shrout and Fleiss 1979) with a value of .91 in the
present study. The inclusion criteria were liberal and similar to
clinical practice criteria. The inclusion criteria were: (a) sat-
isfying DSM-IV criteria for chronic PTSD
1
with symptom
duration more than 6 months, (b) PTSD symptoms identified
as the primary problem in need of treatment, (c) age 20 to
65 years, and (d) accepting withdrawal of all psychotropic
medication (which is standard procedure on the Anxiety Unit
of the psychiatric hospital). The exclusion criteria were: (a)
current suicidal risk, (b) current psychosis, (c) severe disso-
ciative symptoms, or (d) current involvement in an abusive
relationship, which is similar to clinical practice criterion for
prolonged exposure and Imagery Rescripting and
Reprocessing Therapy (IRRT). Using listwise deletion for
missing responses resulted in a sample of 50 patients com-
pleting all items of TRSI on both measurement occasions. The
patients excluded from the analysis did not complete any of
the TRSI items at the first measurement occasion. The missing
data involved in the present study are defined as missing
completely at random. The Little’s test of missing completely
at random (MCAR) based on the 24 items on both measure-
ment occasions indicated that data were missing completely at
random, Littles MCAR χ
2
(6)= 5,434 p= .490. No data were
available for patients with missing data at the first measure-
ment occasion to estimate imputed values for missing re-
sponses. The sample of 50 patients consists of 44 %
men and 56 % women with mean age 45.51 (SD=
9.629) with mean value of 1,201 (SD=.867) and .790
(SD=.799) on internal- and external referenced shame
on a four point Likert scale, respectively. The 50 pa-
tients had experienced a variety of index traumas: 20
(40.8 %) patients had experienced physical assault by a
familiar person, 24 experienced physical assault by a
stranger, 23 accidents, 5 natural disasters, and 14 war-
related traumas. 8 and 10 of the patients were subjected
to sexual assault from a stranger and from a familiar
J Psychopathol Behav Assess
person, respectively. The mean length of time since the
index trauma was 17.5 years (SD=13.3 years).
The Development of the TRSI
This inventory was constructed for exploring the concept of
trauma-related shame. This construct was operationally de-
fined as a negative evaluation of the self in the context of
trauma with a painful affective experience, and a behavioral
tendency to hide and withdraw from others to conceal one’s
own perceived deficiencies. Twenty-eight items that best ap-
proximated the variety of trauma-related shame components
were made after several reconsiderations of item phrases in
English. Theories of emotion in general (Power and Dalgleish
2008) and shame in particular (Gilbert 1997; Gilbert and
Andrews 1998) have led us to sample negative appraisals of
the self, which includes the perception of the self as defective
(internalized shame), and the perception of others’negative
evaluation of the self (externalized shame). Items were written
to represent negative appraisals of the self, affective experi-
ence of shame or action tendencies expressed in withdrawing
behavior. 12 positive items forming a subscale called personal
growth representing positive appraisals of the self were writ-
ten but excluded from the set due to very low correlations with
the remaining items. Contrary to expectation, inter-item cor-
relations indicated that the positively formulated items were
tapping independent constructs rather than a unidimensional
bipolar variable. The items were constructed in collaboration
with two experts in the field to ensure the inclusion of all
relevant aspects of trauma-related shame in the measurement
domain. In the construction of the TRSI, an English version
was made before the translated version. Two experts on
shame, one expert on shame theory in general and one expert
on shame in relation to trauma, participated in the process of
creating the English items and evaluated the relevance and
appropriateness of the items. Expert opinions were based on
the English version of the scale. The English version was then
translated into Norwegian by the fourth author of the present
study. The Norwegian version was then translated back into
English by a bilingual person with English as his native
language without prior knowledge of the original English
items. The final English translation of the TRSI was found
to be in accordance with the original English version of TRSI.
The patients completed the translated Norwegian version in
their native language. An independent conceptual analysis of
the translated version of the scale resulted in the exclusions of
four items due to conceptual ambiguousness of the translated
version of the item formulations.
The patients were asked to rate on a 4-point Likert scale the
presence of specific symptoms of trauma-related shame expe-
rienced during the past 7 days (0= not at all correct about me;
1= sometimes correct about me; 2=mostly correct about me;
3=completely correct about me). The participants were
assured that their responses to the inventory would be strictly
confidential and used for research purposes only.
Procedure
The Trauma Related Shame Inventory (TRSI), the Trauma
Related Guilt Inventory (TRGI) and the Self-compassion
scale (SCS; Neff 2003) were administered to patients with
PTSD during an initial 3-day pre-treatment assessment and
during the first week of their 10-week inpatient program on
the Anxiety Inpatient Unit. The patients were recruited during
an initial 3-day pre-treatment assessment designed to evaluate
eligibility for treatment and to determine their suitability for
the study. Those who met inclusion criteria were fully in-
formed about the study, gave written consent to participate
in the study, and were introduced to the inventory as part of a
measurement battery examining the role of emotions in treat-
ment of PTSD. The patients completed the TRSI, the TRGI
and the SCS, and were then put on a waiting list for the 10-
week inpatient program at the Anxiety Unit. The patients
completed the same inventories at the start of their treatment
approximately 10 weeks later.
Assessments
Self-Compassion Scale (SCS; Neff 2003)contains 26 items
that assess the degree of self-compassion that one is capable of
during times of emotional distress. Participants respond to
various items about “how I typically act toward myself in
difficult times”on a 5-point scale. The inventory consists of 6
subscales tapping self-kindness, self-judgment, common hu-
manity, isolation, mindfulness, and over-identification.
Cronbach’s alpha for the subscale called Self-Judgment used
in the present study was .85. The psychometric properties of
the SCS has previously been investigated in a community
sample by Neff (2003) examining both the internal structure
and relationship between SCS and the Beck Depression
Inventory (BDI; Beck et al. 1961), State-Trait Anxiety
Inventory (Spielberger et al. 1970), and Self-Criticism sub-
scale of the Depressive Experiences Questionnaire (DEQ;
Blatt et al. 1976).
Beck Depression Inventory (BDI-II;Becketal.1996a)isa
21 item self-report scale for assessing degree of cognitive,
affective, motivational, and physiological symptoms of de-
pression during the past seven days. Items are scored on a
four-point scale of symptom severity from 0 (no depression)
to 3 (maximum depression). Various studies have investigated
the psychometric properties of the BDI, e.g., a study by Beck
et al. (1996b) reported a Cronbachs alpha value of .91.
Trauma-related Guilt Inventory (TRGI; Kubany et al.
1996) is a 32 items inventory, which consists of five subscales
to assess different components of trauma-related guilt. The
subscales are called global guilt subscale, the distress
J Psychopathol Behav Assess
subscale, hindsight-bias/responsibility subscale, the wrongdo-
ing subscale, and the lack of justification subscale. The latter
three components are included in the guilt cognition subscale
consisting of 22 items. Items are scored on a five points scale
ranging from 1 (never/not at all true) to 5 (always/extremely
true). Prior studies have demonstrated internal consistency
reliability of .86 and moderate correlations with PTSD and
depression symptoms in a trauma sample (Kubany et al.
1996). For the present study the guilt cognition subscale was
chosen and examined in order to separate trauma-related guilt
from trauma-related shame. In this study, Cronbachs alpha
was .90 for the Guilt Cognition Scale.
The Measurement Design
In this study, trauma-related shame is represented by four
facets, that is four different sources of score variance, within
the measurement design. One facet is called Referent (r) and
includes two different evaluative situational conditions: (1)
Self-referent shame (internal–referent shame), and (2) Other-
referent shame (external-referent shame). The second facet is
labeled Aspect (a). The aspect facet represents different sub-
categories of shame consisting of self-condemnation as the
cognitive component of shame in addition to the affective-
behavioral component of shame. Affective and behavioral
indicators of shame were composed of an affective-
behavioral component due to the lack of behavioral items
available to estimate a separate aspect category consisting of
the behavioral component. Because measurements were col-
lected at two measurement points, the third facet called occa-
sions (o) was included in the design of the study as a random
facet. The fourth facet is items (i) which is nested within (:)
combinations of referents and aspects, and crossed with (x)
occasions. The present multi-facet measurement design p x o
(i:ra) implies that all patients completed the same instruments
on both measurement occasions, in which different items exist
in the aspect categories of self-condemnation and affective-
behavioral component of shame, while the items have equiv-
alent formulation in internal- and external referenced shame.
The descriptive conditions for each facet are presented in
Tab le 1.
Conceptual Analysis of Item Indicators
According to Cronbach et al. (1972) and Kane (1982,2001), a
domain definition that defines the construct is required to
claim generalizability of the score. A conceptual analysis
was therefore carried out by the first author before conducting
the statistical analysis in order to evaluate the correspondence
between each item content and its corresponding shame con-
struct. Three main criteria were critical for accepting the item
as representative indicators of the shame construct. The items
should, in accordance with the theoretical definition of emo-
tion by Power and Dalgleish (2008), represent either: a) a
component of the negative affective experience of shame b)
appraisals in the form of negative evaluations of the self, or c)
action tendencies expressed in withdrawing behavior. Four
items representing the self-condemnation in internal- and
external shame were excluded on the basis of the conceptual
analysis identifying the conceptual ambiguousness of the
Norwegian terms for ‘destroyed’and ‘marked for life’in the
item formulations. Thus, the conceptual analysis resulted in 24
items of trauma-related shame, consisting of six items
representing condemnation and affective-behavioral aspects
of shame with equivalent formulations for internal- and exter-
nal shame (see Table 1). The four different categories were
labeled: Internal Condemnation, Internal Affective-
behavioral, External Condemnation, External Affective-
behavioral. The two first categories constitute internal refer-
enced shame, while the two latter constitute external refer-
enced shame.
Generalizability Theory Applied to the Present TRSI
Design
One of the major advantages of generalizability theory
(G-theory) is that multiple sources of error variance are
estimated simultaneously in a single analysis when in-
vestigating psychometric properties of scores (Shavelson
and Webb 1991). When doing research in real-world
clinical settings one can conceive of a complexity of
sources reflecting measurement error, such as inconsis-
tencies in scores originating from e.g., measurement
occasions, raters, items, among others. These sources
of variation are represented as facets of observation.
Accordingly, G-theory allows the test constructor to
appropriately estimate the generalizability (reliability)
of the scores in a multi-facet measurement design. In
contrast, Cronbach’s alpha coefficient will likely provide
biased estimation of psychometric properties of scores
obtained in such measurement designs (Cronbach and
Shavelson 2004).
A distinct characteristic of G-theory is the distinction made
between reliability involving absolute decisions, which is
relevant if clinical decisions are based on individual’sscore,
and relative decisions involving stability in relative standing
or rankings of persons (Shavelson et al. 1989;Brennan2003;
Feldt and Brennan 1989). This distinction is important and
needed in clinical practice because most clinical decisions
concern the standing of a given patient with regards to criteria
used for determining clinical intervention (absolute deci-
sions). These two types of relevant coefficients can be esti-
mated to represent different definitions of measurement error.
J Psychopathol Behav Assess
The coefficient of generalizability, Eρ
2
,isrelevantwhenthe
researcher is concerned with decisions involving relative
standing or ranking of individuals. The multiple errors or
threats to generalization of relative decisions are compressed
in the variance term, σ
2δ
, labeled relative error and includes all
the variance components involving interactions between per-
sons and facets of observations in Table 2. The relative G-
coefficient (Ep
2
) is defined as the ratio between universe score
(or true score) variance, σ
2
p
, and observed variance consisting
of the sum of relative error variance, σ
2δ,
and the universe
score variance σ2p; σ2p/(σ2δ+σ2p). The G–coefficient is
then interpreted as the amount of observed variance that is
accounted for the by universe score variance.
The other definition of measurement error is involved when
estimating the other type of generalizability coefficient called
index of dependability, Φ, (Brennan 1983; Shavelson and
Web b 1991). This coefficient is relevant when making absolute
decisions based on the absolute level of an individual’sscore
(e.g., a patient score in relation to a given clinical cut-off criteria).
The multiple errors involved in the present study in absolute
decisions include all variance components in Table 2except the
person component, σ
2
p.
The multiple error components for ab-
solute error are compressed in the term, σ
2Δ
.The index of
dependability is defined by the ratio σ
2
p/ (σ
2Δ
+σ
2
p)
.
In addition, generalizability theory provides information
for optimizing multi-facet measurement design to minimize
the influence of measurement error by alternating sample sizes
of facets of observation (Brennan 2010). This is especially
relevant for the second research question in suggesting a
measurement design for short form scales with the aim of
optimizing the number of items without narrowing the con-
struct domain.
In the third research question we want to investigate the
differentiation between shame and guilt measured by the
TRSI and the guilt cognition scale. In the present data context,
this research question can be approached by estimating the
generalizability of the differences scores (Brennan et al. 1995)
representing the distinction between guilt and shame. The
reliability of difference scores among guilt and shame can be
estimated by means of univariate generalizability study
(Eikeland 1973)
.
A generalizability coefficient representing
the reliability of the distinction between shame and guilt
was estimated by a formula corresponding to the formula
for estimating a relative generalizability coefficient
outlined above.
In the present pi:c design in which the interaction between
person (p) by items (i) is nested within construct categories (c)
of shame and guilt, respectively, the “person by construct”(pc)
Tabl e 1 Measurement design of trauma related shame inventory: four facet p x o (i:ra) design
Referent facet (r)
Internal shame External shame
Occasion 1 and 2 (o) Occasion 1 and 2 (o)
Aspect
Facet (a)
Condemnation Items (i)
1. As a result of my traumatic experience,
I have lost respect for myself.
5. As a result of my traumatic experience,
I cannot accept myself.
10. As a result of my traumatic experience,
I find myself less desirable.
13. As a result of my traumatic experience,
there are parts of me that I want to get rid of.
15. Because of my traumatic experience,
I feel inferior to others
21. As a result of my traumatic experience,
Idon’t like myself
Items (i)
12. If others knew what had happened to me, they
wouldlookdownonme
17. If others knew what happened to me, they would
find me unacceptable.
2. Because of what happened to me, others find
me less desirable.
4. As a result of my traumatic experience, others have
seen parts of me that they want nothing to do with.
6. If others knew what happened to me, they would
view me as inferior
14. If others knew what happened to me, they would
not like me
Affective-Behavioral 3. I am ashamed of myself because of what
happened to me.
8. I am ashamed of the way I behaved during
my traumatic experience.
9. I am so ashamed of what happened to me
that I sometimes want to escape from myself.
11. I am ashamed of the way I felt during my
traumatic experience.
20. My traumatic experience has revealed a part
of me that I am ashamed of.
23. Because of what happened to me, I am
disgusted with myself.
16. If others knew what happened to me, they would
be ashamed of me.
19. If others knew how I behaved during my traumatic
experience, they would be ashamed of me.
24. I am so ashamed of what happened to me that I
sometimes want to become invisible to others.
22. If others knew how I felt during my traumatic
experience, they would be ashamed of me.
18. As a result of my traumatic experience, a part of
me has been exposed that others find shameful.
7. If others knew what happened to me, they would
be disgusted with me.
J Psychopathol Behav Assess
interaction term indicates to what extent a person’srankorderof
universe scores differs across the two construct categories of
shame and guilt. The estimated pc-component represents the
universe score variance for the difference score. The estimate of
the relative error variance, σ
2δ
, which is now the σ
2
pi:c
/n
i
component where n
i
is the number of items applied in the
estimation. Thus the generalizability coefficient for the differ-
ence score between the two constructs guilt and shame, Eρ
2
diff
,
is σ
2
pc/ (σ
2
d
+σ
2
pc). It should noticed that in the applied p x i:c
design, the number of items, n
i
, within the TRSI and guilt
cognition scale is 24 and 22, respectively. Due to the present
unbalanced design, the estimation of the variance components
was conducted by means of the software program urGENOVA
(Brennan 2001a,b). n
i
=22 was applied when estimating the
generalizability of the difference score. The generalizability
coefficient for the difference score between TRSI and guilt
cognition indicates to what extent the universe score variance
of the pc - interaction or the universe difference score variance
accounts for variance in the observed difference scores.
Alternatively, high reliability of the difference scores between
shame and guilt would indicate that the mean correlation
among items within the constructs is higher than the mean
correlation among items across the constructs. This pattern of
correlations indicates support for differential construct validity
(Eikeland 1973).
G-theory makes also a distinction between a G-study and a
D-study. G-study estimations of the variance components are
presented in Tables 2and 3. These variance components
display the relative importance of sources of variation in a
typical observation or in an average observation in the design.
A D-study, on the other hand, estimates generalizability coef-
ficients for a composite of scores where error components are
reduced by increasing the sample sizes of the facets of obser-
vations. For further information about G-theory and analysis
the reader is referred to Shavelson and Webb (1991), and
Brennan (1992a,b,2001a,b).
The generalizability studies were performed by GENOVA,
a program developed for univariate generalizability analyses
with balanced design (Crick & Brennan 1983). Multivariate
generalizability analysis, performed by the program software
mGENOVA (Brennan 1999) was also applied to explore the
internal structure of the test design aswill be elaborated below.
The application of multivariate generalizability analysis to
examine the covariance composition of the measurement de-
sign involving four categories from the combinations of two
fixed facets (internal and external shame) has been suggested
by Brennan (1994 p.189).
Results
Univariate Generalizability Analysis
The internal structure of the trauma-related shame was first
examined by assessing the variance component structure esti-
mated by univariate generalizability study. Based on the p x o
(i:ra) design, 19 G-study variance components were estimated
Tabl e 2 Estimated G-study Var-
iance Components for Trauma
Related Shame Inventory Based
on Random Model: p x o (i:ra)
Design (N=50)
σ
2
= variance component, σ
(σ
2α
) = Standard error of vari-
ance component % = Percentage
variance of total variance.
1
Items
nested within referent and aspect
Source d.f σ
2
%σ(σ
2α
)
Persons p 49 .4090 37.15 % .09733
Referents r 1 .0831 7.54 % .06834
Aspects a 1 .0194 1.76 % .01675
Occasions o 1 .0040 .36 % .00538
Items
1
i:ra
1
20 .0224 2.00 % .00841
Persons by referents pr 49 .0130 1.18 % .01742
Persons by aspects pa 49 .0000 .00 % .01216
Persons by occasions po 49 .0850 7.72 % .02324
Persons by items
1
pi:ra
1
980 .1180 10.72 % .01285
Referents by aspects ra 1 .0000 .00 % .00158
Referents by occasions ro 1 .0000 .00 % .00028
Aspects by occasions ao 1 .0014 .12 % .00137
Occasions by items
1
oi:ra
1
20 .0006 .54 % .00180
Persons by referents by aspects pra 49 .0435 3.95 % .01778
Persons by referents by occasions pro 49 .0299 2.71 % .01141
Person by aspects by occasions pao 49 .0030 .27 % .00686
Person by referents by aspects by occasions prao 49 .0013 .11 % .00930
Referents by aspect by occasions rao 1 .0000 .00 % .00048
Residuals poi:ra,e 980 .2671 24.26 % .01205
J Psychopathol Behav Assess
with GENOVA. The variance components from the univariate
generalizability analysis are presented in Table 2.
In the present multi-facet study design, the person compo-
nent (p), representing the universe scores (which is equivalent
to true scores), accounted for a major part of the total variance
and reflected that variance in scores are systematically related
to individual differences in shame. Most of the remaining
variance components representing sources of variance related
to items, occasions, aspects and referents, and interactions
among these sources of variance contributed negligibly to
the score variance with some exceptions. Two major sources
of variation in test scores were the “persons by items nested
within referents by aspects”(pi:ra) and the “persons by occa-
sions by items nested within referents by aspect”component
(poi:ra) accounted for about 11 % and 24 % of total variance,
respectively. The first variance component (pi:ra) indicated
how much persons rank order differs across items nested
within the aspect by referent categories. The latter variance
component indicated instability in the persons rank order
across items within the aspect by referent categories on dif-
ferent measurement occasions. Each of the variance compo-
nents for the referents facet (r) and the interaction component
“persons by occasions”(po) accounted for about 8 % of the
total variance. The “person by occasion”(po) interaction term
indicates to what extent a person’srankorderdiffersacrossthe
measurement occasions. The variance components associated
with occasions (o) and interaction between occasions and
persons (po) were small in magnitude indicating stability of
the measured scores. The referents facet (r) indicates little
variations in mean scores for the distinction between
Tabl e 3 Estimated G-study vari-
ance and covariance components
for trauma related shame inven-
tory based on p•xo•xiºdesign
1
(N=50)
1
p•xo•x iº Design implies that
all persons completed all items at
both measurement occasions.
2
Upper diagonal elements show
correlations between the four as-
pect categories. Lower diagonal
elements show covariances be-
tween the four aspect categories.
3
Source Internal referenced Shame External-referenced Shame
Condemnation Affective-
behavioral
Condemnation Affective-
behavior
Persons (p).49819
2
.82632 .87653 .90738
.44509 .58237 .89393 .90570
.38675 .42645 .39078 1.04422
.39175 .42277 .39928 .37415
Occasions (o)−.00031
.00422 .00688
.00107 .00184 −.00095
.00632 .00990 .00235 .01068
Items (i)−.00087
.02079
.02918
.04056
Persons by Occasions (po).12031
.11162 .12845
.07393 .11122 .10695
.05896 .10232 .11848 .12199
Persons by Items (pi).12487
.07654
.12882
.14211
Occasions by Items (oi).00589
−.00158
−.00286
.00095
Residuals (poi).29244
.32458
.26852
.18305
Relative contribution to
composite universe score
25.36 % 27.64 % 23.61 % 23.39 %
J Psychopathol Behav Assess
internal- and external referenced shame. Likewise, the aspects
facet (a) also indicates little variations in mean scores of
condemnation and affective-behavioral components of shame.
All the variance components appeared to be rather stable
estimates based on the estimated standard errors (see Table 2).
Of specific interest was the small variance component
“person by referents”(pr) compared to the large person com-
ponent (p). The relative size of the person- and the person by
referent-components indicates relatively strong stability in
persons rank order across internal and external referenced
shame. Likewise, the small variance component of “person
by aspects”(pa) relative to the large person component (p)
indicates relatively strong stability in persons rank order
across the different aspects of trauma-related shame consisting
of condemnation of the self and affective-behavioral compo-
nents of shame. The small variance components of “persons
by referents”(pr), “persons by aspects”(pa) and “persons by
referents by apects”(pra) might indicate a relative strong
correlation between referents and aspects, respectively.
These results motivate the use of multivariate generalizability
analysis to further explore the internal structure in terms of the
correspondence among the four fixed categories representing
internal condemnation, internal affective-behavioral, external
condemnation, and external affective-behavioral components
of trauma related shame. Thus, the univariate component
structure suggested relative strong correlations between the
two referents categories (internal and external referenced
shame), between the two aspects categories (condemnation
and affective-behavioral components of shame), and also
between all four categories from the combination of the ref-
erents and aspects categories.
Multivariate Generalizability Analysis
The univariate analysis does not explicitly inform about the
relationship between the referent and aspect categories. To
further examine the internal structure of the TRSI and in terms
of the homogeneity of the scores, we utilized a multivariate
generalizability study to estimate the covariance components
structure of the four categories from the combinations of two
fixed facets in the present. This design has been suggested by
Brennan (1994 p.189). The present multivariate design p•xo•
x iº implies that all persons completed all items on both
measurement occasions. The multivariate generalizability
analysis is reported in Table 3.
The covariance components structure clearly suggested
that the measured construct of trauma-related shame may be
homogeneous in nature rather than consisting of distinct cat-
egories of internal and external-referenced shame. In the pres-
ent multivariate study design, the largest components are the
person components (p), representing the universe scores,
which accounts for approximately 48 % and 51 % of the total
variance for personal condemnation and the affective-
behavioral component of internal shame, respectively, and
about 27 % and 43 % of the total variation for perceived
condemnation and affective-behavioral component of
external-referenced shame, respectively. The relative contri-
bution to the composite universe score from the
Condemnation and Affective-behavioral components within
the internal- and external-referenced shame were 25.36 %,
27.64 %, 23.61 % and 23.39 %, respectively (see Table 3).
While the high correlations among the four universe scores
support the existence of a general component, the relative
contributions suggests that the four variables contributed
about the same amount of variance to the composite shame
score. The covariance components structure clearly suggested
that the measured construct of trauma-related shame may be
homogeneous in nature rather than consisting of distinct cat-
egories of internal and external-referenced shame. In sum,
both the relative size of the person component in the univariate
analysis and the homogeneous composition of the covariance
matrix for persons estimated by the multivariate analysis,
suggested that all the four categories share a strong common
underlying component.
Decision Studies
By systematically examining the various sources of measure-
ment error, G-theory provides information for optimizing the
design by reducing measurement error. Decision studies (D-
studies) provide generalizability coefficients tailored to the
intended use of the measurement. The variance and covari-
ance components derived from the multivariate analysis in
Tab le 3were used as input for estimation of generalizability
coefficients in D-studies. At the D –study level measurement
conditions with different numbers of items (6, 3, 2 and 1)
nested within each of the four aspect categories, respectively,
were specified. As presented in Table 4, both the G-
coefficients associated with relative decisions and absolute
decisions are high even for four items. The results from the
D-study analyses displayed little variation in estimated G-
coefficients and indexes of dependability for different num-
bers of indicators. This would imply that four items are
sufficient for generalizability coefficient and index of depend-
ability of .77 (see Table 4).
Reliability of Difference Scores Between Shame and Guilt
The third research question, involving differential construct
validity between shame and guilt, was evaluated by estimating
the reliability of the difference scores based on the variance
components derived from the univariate generalizability study
(Brennan 2001a,b) with the pi:c design. The pc and the
relative error component were estimated to be .17 and .82/
22= .039. Inserted in the relevant formula presented above, the
estimated G-coefficient for the difference score was .813
J Psychopathol Behav Assess
based on 22-item version of the guilt cognition scale and the
TRSI. Thus the distinction between guilt cognition and shame
is highly generalizable. The high generalizability coefficient
of .812 based on 22-item version of the guilt cognition scale
and the TRSI in Equation 1 shows that the distinction between
guilt and shame is highly reliable. The consistency of scores
across items within the constructs is relatively stronger than
the consistency of scores across items across the two con-
structs, indicating support for the two separate constructs of
shame and guilt.
External Validation for Construct Validity Interpretation
A linear regression model was first utilized to examine the
proposed relationship between TRSI and depression when
correcting for the alternative interpretation represented by
guilt. TRSI total scores were significantly related to the Self-
Judgment scores (r =.52,p<.001). The correlations between
TRSI and guilt cognitions and depression were .58 (p<.001)
and .49 (p<.001), respectively. Two separate multiple regres-
sion analyses were then executed to control for guilt cogni-
tions. Significant unique relationships were obtained between
TRSI and a) Self-Judgment and b) depression indicated by
partial standardized regression coefficient of .56 (p<.05) and
.40 (p<.05), respectively. This finding indicates that only
shame had an unique effect on Self-Judgment and depression,
while guilt was not uniquely related to Self-Judgment and
depression.
Discussion
In this article, univariate and multivariate generalizability
analysis were applied to examine the first research question
regarding the psychometric properties and the internal struc-
ture of the Trauma-related Shame Inventory (TRSI) by the
estimation of different sources of score variance. Both the
univariate and the multivariate generalizability study
displayed a large person component relative to the remaining
sources of variance, including the interaction components
involving persons, occasions and items. The present results
from the first research question indicated that the TRSI is
constructed to be sensitive enough to capture considerable
variability between persons in trauma-related shame. The
results indicated that the score variance to a large extent
reflected individual differences in shame with little influence
from other remaining sources of variance representing items,
occasions, aspects and referents categories. By including the
facet of items, aspects, and occasions in the present measure-
ment design, we estimated a generalizability coefficient of the
scores by taking into consideration measurement errors related
to variability in scores from one occasion to another, diversity
in scores at the level of items, aspects and referent categories
(internal and external referenced shame) along with different
combinations of sources of measurement errors. Both the
composite G-coefficient and index of dependability for the
measurement design p•xo•x iº consisting of 24 items were
high, .87 and .87 respectively, suggesting that the TRSI
yielded reliable scores and provided an acceptable index of
shame in traumatized individuals with little influence of mea-
surement errors. The high index of dependability also suggests
that the TRSI is precise enough to be used for screening
purposes. In addition, a multivariate generalizability analysis
revealed strong positive correlations among the components
of shame to include condemnation and affective-behavioral
components for internal- and external referenced shame.
In accordance with shame theory (Gilbert and Andrews
1998;Gilbert2000), internal and external-referenced shame
should be correlated because they are part of the same con-
struct of shame. However, shame theory does not specify how
strongly internal and external-referenced shame should be
correlated. Correlations in the range of .82 to .90 between
aspect categories across internal- and external-referenced
shame suggest that a general component of trauma-related
shame can be estimated. Despite the meaningfulness of the
theoretical distinction between the two different evaluative
perspectives in trauma-related shame, our data indicate a
fusion of internal and external shame as measured by the
TRSI. Lewis (1995) refers to the fusion of external and inter-
nal shame in his conceptualization of “the exposed self”.The
perception of being judged and shamed by others has been
understood by some researchers as a form of externalized
projections of ones own self-condemnation (Wilson et al.
2006); that is, experiencing the psychological pain from con-
demnation of oneself may result in fear linked to an expecta-
tion of devaluation from others. As such, when experiencing
shame related to traumatic incidents, an individual may erro-
neously conclude on the basis of a critical self-evaluation that
the outside world will turn against him or her (Wilson et al.
Tabl e 4 Estimated D-study Statistics for Total Scores Derived from the
Multivariate G-study in Table 2with Total Number of Items in Each D-
Study Equal to 24, 12, 8 and 4, respectively
D-Study
n′=6
1
n′=3
1
n′=2
1
n′=1
1
σ
2
= .42435 .42435 .42435 .42435
σ
2
(δ) = .06145 .07193 .08242 .11388
σ
2
(Δ) = .06458 .07604 .08751 .12190
Eρ
2
= .87351 .85506 .83737 .78842
Φ= .86792 .84803 .82904 .77684
1
Number of items within each of the four aspect categories
σ
2
= universe score variance, σ
2
(δ) = relative measurement error, σ
2
(Δ) = total measurement error, Eρ
2
= Generalizability coefficient, Φ=
Index of dependability
J Psychopathol Behav Assess
2006). As a consequence the shame-ridden traumatized indi-
vidual may hide perceived flaws and display avoidance be-
havior out of fear from condemnation and rejection of other
people (Lindsay-Hartz 1984; Tangney 1991; Greenberg and
Paivio 1997;Lewis1995; Nathanson 1987; Stone 1992;
Tan gney 1991; Tomkins 1987).
The very high correlation between the two aspect condi-
tions in both internal- and external referenced shame suggests
that responses to indicators of self-condemnation do not differ
from responses to affective and behavioral indicators of
trauma-related shame. This finding may illustrate that con-
demnation is a core feature of trauma-related shame in which
condemnation of the self is strongly related to affective and
behavioral components of shame. Broader theoretical views
emphasize condemnation of the self in the very definition of
shame (Lewis 1995; Tangney et al. 1996). Tangney defined
shame as negative condemnation of the whole self (Tangney
et al. 1996). Both Lewis (1995) and Gilbert’s(1997,Gilbert
and Andrews 1998) theorizing of shame emphasizes the neg-
ative self-evaluative aspect. A major contribution to the field
was advanced by Lewis (1971) contending that self-
awareness is a prerequisite for the individual to experience
shame. In this regard, the source of shame is one’sthoughts
about oneself, which involves being self-absorbed in one’s
own perceived personal defects. However, some researchers
do not view shame as a self-conscious emotion, but as a
primary physiological response to the threat of isolation and
thus ignore the role of self-evaluation in shame (Martens
2005). This is unfortunate because it limits the possibility of
explaining why individuals have different shame cognitions to
the same traumatic events. The results of our study support the
notion advanced by most theorists in the field that condemna-
tion of the self is a core component of shame.
The second research question relates to the design of a
short-form measurement that provides optimal reliability.
Applying G-theory allows the test constructor to estimate
generalizability in a multi-facet measurement design. In addi-
tion, generalizability coefficients tailored to the specific use of
the measurement are estimated in different measurement de-
signs with different number of items within each of the four
components of shame. Within the framework of G-theory, the
present study started with a larger number of items designed to
accurately estimate the variance components. While 24 items
were used to estimate the G-study variance components, the
results from the D-studies suggest that eight items (that is, two
items for each of the four fixed categories) are sufficient to
provide composite generalizability and index of dependability
coefficients above .80 for trauma related shame scores, while
four items are sufficient for composite generalizability coeffi-
cient and index of dependability of .77 (see Table 4). As noted
by Smith et al. (2000), the precision of the instrument and
validity of the inferences drawn from the scores of an instru-
ment must be preserved, especially when a more lengthy
assessment is deemed essential by the original test developers.
However, reducing a full-scale measurement to a small set of
items could result in narrowing the measurement domain. As
such, the possible loss of validity for saving time is not
preferable. Because assessment scores are frequently used to
make critical decisions with regard to clinical interventions,
the use of short-form measures for clinical use poses heavy
demands of measurement precision and validity. Decisions
concerning whether patients are in need of clinical interven-
tion targeting shame or whether the patient has improved as a
result of clinical intervention, suggest the need for research to
investigate whether a short-form version of an instrument is
precise enough for this particular use.
The third research question relates to the divergent validity
of shame and guilt. In the process of creating the TRSI, a sharp
conceptualdistinction between shame and guilt has enabled us
to create a measurement that separates these two self-
evaluative emotions. While shame and guilt seems to be
related to each other and often occur together, they are never-
theless treated as two distinct emotions in theory. The rela-
tionship between shame and guilt is meaningful, in which
guilt may elicit shame from attribution processes if the indi-
vidual see one’s behavior as confirming evidence of personal
failure. The high generalizability coefficient of the difference
scores among guilt and shame of .821 in the present study
indicates that shame and guilt are separable and two distinct
emotions, in which mean correlation among items within the
TRSI is higher than mean correlations among items across the
TRSI and the TRGI. This particular generalizability estima-
tion can be considered an aspect of construct validity labeled
differential construct validity by Eikeland (1973).
The fourth research question relates to the relationship
between the TRSI scale, BDI, and the subscale of Self-
Judgment. According to recent thinking in validity theory,
later developments have emphasized some general princi-
ples inherent in the construct validity model (Kane 2001).
A central point is assessment of proposed interpretations
of test scores, as well as considering possible competing
interpretations. The general question is whether the rela-
tionships found between TRSI, depression and self-
judgment are due to the influence of a third set of
variables (e.g., guilt). If scores on the TRSI are related
to the Self-Judgment and depression independent of guilt
cognitions, then the results will further provide supporting
evidence towards construct validity. The TRSI scale
passed a stringent test, with the demonstration that both
the relationships between the TRSI and depression and
internal shame measured by the subscale Self-Judgment
was independent of the influence of guilt cognitions.
J Psychopathol Behav Assess
Both the homogeneous composition of the TRSI scores
and the high regression coefficient values between the
TRSI and Self-Judgment and depression while controlling
for guilt cognitions provide supporting evidence towards
construct validity.
Clinical Implications
The need for an assessment of trauma-related shame is essen-
tial given the revised DSM-V criteria for PTSD to include
shame and guilt. However, no measure available assesses
shame in the context of trauma, and gold standard assessments
of PTSD do not include shame and guilt. Furthermore, treat-
ment studies of PTSD have focused on other emotions (e.g.,
fear, anger, guilt) or depression, and trauma-related shame is
typically investigated only as subordinate outcome in PTSD
treatment trials. In particular, the recent focus on treatment of
moral injury in war veterans suggests the role of trauma-
related shame in PTSD with implications for treatment
(Smith et al. 2013; Steenkamp et al. 2013). The TRSI might
then serve as a useful screening and evaluation measure as
well as a measure of change in PTSD treatment in general, and
in particular in the treatment of veterans with PTSD.
Our results indicate that shame in the context of trauma is a
uniform phenomenon. Accordingly, shame can be treated by
one treatment method, and there may be no need to develop
specific methods for treating internal versus external shame.
Limitations
Results of the present study indicate a fusion of internal and
external shame as measured by the TRSI. However, one cannot
rule out the possibility that the operationalization of internal- and
external shame in the TRSI items may be too similar, and thereby
obscure distinct features of internal and external shame. Our
strategy of using identical formulation of indicators differing with
reference to the internal- and external shame could lead to more
homogenous responses in which relevant aspects of this distinc-
tion are not made explicit. On the other hand, the identical
formulation of indicators with reference to internal and external
shame enabled us to estimate the covariance components struc-
ture of the four aspect conditions in the present multivariate
measurement design. The two referenced norms, internal and
external- referenced shame, represent nevertheless an important
issue that deserves more attention in the future.
The results displayed overall high correlations between the
four universe scores. However, a correlation value of 1.044 in
the multivariate generalizability study in Table 3is slightly out
of range. Given the small sample of 50 persons this value may
be caused by sampling error rather than misspecification of
the model. The small sample size of 50 participants in the
present study has the potential to result in unstable estimates.
However, all the variance components appeared to be rather
stable estimates based on the estimated standard errors in a
univariate G-study (see Table 2).
Future Research
While the results from this study are encouraging, replication
studies are needed to investigate whether similar results
emerge from other independent samples, preferably with the
use of confirmatory factor analysis on a larger sample size. A
possible extension of this inquiry would be to measure the
TRSI components by shorter scales than the one used in this
domain study. Selection and reduction of item indicators to
eight or four items may be better assessed by the improved
methodology of confirmatory factor analysis or item response
theory as supplements to G-theory.
Conclusion
While the availability of scales for identifying shame in trau-
matized patients appears to be crucial, there is to date no
measure of assessing shame within the context of trauma.
The present study provides support for using the 24-item
version of the TRSI in both clinical practice and research.
Assessing trauma-related shame in clinical research can en-
hance our understanding of negative emotions following trau-
ma. This instrument is also suitable for investigating clinically
relevant theory-derived hypotheses regarding trauma-related
shame as a maintaining factor in treatment studies of PTSD. A
high index of dependability indicating low influence of abso-
lute measurement errors suggests the utility of the TRSI for
screening purpose. The dependability of the scores allows
both researchers and clinicians to use the TRSI as a screening
instrument, as well as an assessment of shame with high
degree of confidence. This increased confidence has the po-
tential to identify shame in traumatized individuals that would
result in early identification and choice of intervention tailored
to the patient symptom profile.
Conflict of Interest There are no conflicts involved in the present study.
Experiment Participants The study was approved by the Regional
Ethics Committee and the patients gave informed consent after the
procedure had been fully explained.
J Psychopathol Behav Assess
Appendix
References
Andrews, B., Qian, M., & Valentine, J. (2002). Predicting depressive
symptoms with a new measure of shame: the experience of shame
scale. British Journal of Clinical Psychology, 41,29–42.
Arntz, A., Tiesema, M., Kindt, M. (2007). Treatment of PTSD: a com-
parison of imaginal exposure with and without imagery rescripting.
Journal of Behavior Therapy and Experimental Psychology, 38(4),
345–370.
Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961).
An inventory for measuring depression. Archives of General
Psychiatry, 4,561–571.
Beck, A. T., Steer, R. A., & Brown, G. K. (1996a). Manual for beck
depression inventory-II. San Antonio: Psychological Corporation.
Beck, A. T., Steer, R. A., Ball, R., & Ranieri, W. (1996b). Comparison of
beck depression inventories IA and II in psychiatric outpatients.
Journal of Personality Assessment, 67,588–597.
Beck, J. G., McNiff, J., Clapp, J. D., Olsen, S. A., Avery, M. L., &
Hagewood, J. H. (2011). Exploring negative emotion in women
experiencing intimate partner violence: shame, guilt, and PTSD.
Behavioral Therapy, 42,740–750.
Benson, J., & Hagtvet, K. A. (1996). The interplay among design, data
analysis and theory in the measurement of coping. In S. Norman,
Endler, & Z. Moshe (Eds.), Handbook of coping: Theory, research,
applications (Vol. 5, pp. 83–106). New York: Wiley.
Table 5 Trauma-Related Shamess Inventory (TRSI-24 item English
version). Individuals who experience traumas often have many different
types of reactions. Below are a number of statements that describe
thoughts and feelings that people sometimes have about themselves.
Please read each statement carefully, and decide how much it applies to
you check the option that best describes how much the statement is true
for you over the past week
Not true
of me
Somewhat
true of me
Mostly
true of me
Completely
true of me
(I) As a result of my traumatic experience, I have lost respect for myself ☐☐ ☐ ☐
(E) Because of what happened to me, others find me less desirable ☐☐ ☐ ☐
(I) I am ashamed of myself because of what happened to me ☐☐ ☐ ☐
(E) As a result of my traumatic experience, others have seen parts of me
that they want nothing to do with
☐☐ ☐ ☐
(I) As a result of my traumatic experience, I cannot accept myself ☐☐ ☐ ☐
(E) If others knew what happened to me, they would view me as inferior ☐☐ ☐ ☐
(E) If others knew what happened to me, they would be disgusted with me ☐☐ ☐ ☐
(I) I am ashamed of the way I behaved during my traumatic experience ☐☐ ☐ ☐
(I) I am so ashamed of what happened to me that I sometimes want to
escape from myself
☐☐ ☐ ☐
(I) As a result of my traumatic experience, I find myself less desirable ☐☐ ☐ ☐
(I) I am ashamed of the way I felt during my traumatic experience. ☐☐ ☐ ☐
(E) If others knew what had happened to me, they would look down on me ☐☐ ☐ ☐
(I) As a result of my traumatic experience, there are parts of me that I want
to get rid of
☐☐ ☐ ☐
(E) If others knew what happened to me, they would not like me ☐☐ ☐ ☐
(I) Because of my traumatic experience, I feel inferior to others ☐☐ ☐ ☐
(E) If others knew what happened to me, they would be ashamed of me ☐☐ ☐ ☐
(E) If others knew what happened to me, they would find me unacceptable ☐☐ ☐ ☐
(E) As a result of my traumatic experience, a part of me has been exposed
that others find shameful
☐☐ ☐ ☐
(E) If others knew how I behaved during my traumatic experience, they would
be ashamed of me
☐☐ ☐ ☐
(I) My traumatic experience has revealed a part of me that I am ashamed of ☐☐ ☐ ☐
(I) As a result of my traumatic experience, I don’t like myself ☐☐ ☐ ☐
(E) If others knew how I felt during my traumatic experience, they would be
ashamed of me
☐☐ ☐ ☐
(I) Because of what happened to me, I am disgusted with myself ☐☐ ☐ ☐
(E) I am so ashamed of what happened to me that I sometimes want to become
invisible to others
☐☐ ☐ ☐
IInternal Shame, EExternal shame
J Psychopathol Behav Assess
Blatt, S. J., D’Afflitti, J., & Quinlan, D. (1976). Experiences of depression
in young adults. Journal of Abnormal Psychology, 65,383–389.
Blum, A. (2008). Shame and guilt, misconceptions and controversies: a
critical review of the literature. Trau ma tol ogy, 14,91–102.
Brennan, R. L. (1983). Elements of generalizability theory.IowaCity:
American College Testing.
Brennan, R. L. (1992a). Generalizability theory. Educational
Measurement: Issues and Practice, 11,225–232.
Brennan, R. L. (1992b). Elements of generalizability theory.IowaCity:
ACT.
Brennan, R. L. (1994). Variance Components in Generalizability Theory.
In R. R. Cecil (Ed.), Cognititive assessment –a multidisciplinary
perspective (pp. 175–206). New York: Plenum Press.
Brennan, R. L. (1999). Manual for mGENOVA. Iowa testing programs
occasional papers number 47.
Brennan, R. L. (2001a). Manual for urGENOVA. Iowa City: Iowa Testing
Programs, University of Iowa.
Brennan, R. L. (2001b). Generalizability theory. New York: Springer.
Brennan, R. L. (2003). Coefficients and Indices in Generalizability
Theory. Center for Advanced Studies in Measurement and
Assessment, CASMA Research Report, 1,1–44.
Brennan, R. L. (2010). Generalizability theory and classical test theory.
Applied Measurement in Education, 24,1–21.
Brennan, R. L., Gao, X., & Colton, D. A. (1995). Generalizability
analyses of work keys listening and writing tests. Educational and
Psychological Measurement, 55(2), 157–176.
Brewin, C. R., Dalgleish, T., & Joseph, S. (1996). A dual representation
theory of posttraumatic stress disorder. Psychological Review, 103,
670–686.
Cook, D. R. (1988). Measuring shame: the internalized shame scale.
Alcoholism Treatment Quarterly, 4,197–215.
Cook, D. R. (1989). Internalized Shame Scale (ISS). Stout: University of
Wisc onsi n.
Cook, D. R. (1991). Shame, attachment and addictions: implications for
family therapists. Contemporary Family Therapy, 13,405–419.
Cook, D. R. (1993). The internalizedshame scale manual. Channel Press,
Menomonie, WI (Available from author; Rt. 7, Box 270a,
Menomonie, WI 54751, U.S.A.).
Cronbach, L. J., & Shavelson, R. J. (2004). My current thoughts on
coefficient alpha and successor procedures. Educational and
Psychological Measurement, 64,391–418.
Cronbach, L. J., Gleser, G. C., Nanda, H., & Rajaratnam, N. (1972). The
dependability of behavioral measurements: Theory of generalizabil-
ity for scores and profiles. New York: Wiley.
DePrince, A. P., Zurbriggen, E., Chu, A. T., & Smart, L. (2010).
Development of the Trauma Appraisal Questionnaire. Journal of
Aggression, Maltreatment, and Trauma, 19,275–299.
Donders, J. (1997). Using a short form of the WISC-III: sinful or Smart?
Child Neuropsychology, 7,99–103.
Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic
stress disorder. Behavioral Research Therapy, 38,319–345.
Eikeland, H.-M. (1973). Generalizability estimates for differenece scores:
An aspect of the construct validity of tests. Departmental Research
Report, University of Oslo. https://bora.uib.no/bitstream/handle/
1956/4803/Generalizability.pdf
Feldt, L. S., Brennan, R. L. (1989). Reliability. In R. L. Linn (Ed.),
Educational Measurement (3rd ed) (pp. 105–146).
Foa, E. B., Riggs, D. S., Dancu, C. V., & Rothbaum, B. O. (1993).
Reliability and validity of a brief instrument for assessing post-
traumatic stress disorder. JournalofTraumaticStress,6,459–474.
Gilbert, P. (1997). The evolution of social attractiveness and its role in
shame, humiliation, guilt and therapy. British Journal of
Medicational Pscychology, 70,113–147.
Gilbert, P. (2000). The relationship of shame, social anxiety and depres-
sion: the Role of the evaluation of social rank. Clinical Psychology
and Psychotherapy, 7,174–189.
Gilbert, P., & Andrews, B. (1998). Shame: Interpersonal behavior, psy-
chopathology, and culture (pp. 99–125). New York: Oxford
University Press.
Gilbert, P., & Miles, J. N. V. (2000). Sensitivity to putdown: its relation-
ship to perceptions of shame, social anxiety, depression, anger and
self–other blame. Personality and Individual Differences, 29,757–
774.
Gilbert, P., & Procter, S. (2006). Compassionate mind training for
people with high shame and self-criticism: Pilot study of a
group therapy approach. Clinical Psychology and
Psychotherapy, 13,353–379.
Greenberg, L. S., & Paivio, S. C. (1997). Working with the emotions in
psychotherapy. New York: Guilford.
Grunert, B. K., Smucker, M. R., Weis, J., & Rusch, M. D. (2003). When
prolonged exposure fails: adding an imagery-based cognitive
restructuring component in the treatment of industrial accident vic-
tims suffering from PTSD. Cognitive and Behavioral Practice,
10(4), 333–346.
Grunert, B. K., Weis, J. M., Smucker, M. R., & Christianson, H. F.
(2007). Imagery rescripting and reprocessing therapy after failed
prolonged imaginal exposure for post-traumatic stress disorder fol-
lowing industrial injury. Journal of Behavior Therapy and
Experimental Psychiatry, 38,317–328.
Harman, R., & Lee, D. (2010). The role of shame and self-critical
thinking in the development and maintenance of current threat in
post-traumatic stress disorder. Clinical Psychology and
Psychotherapy, 17,13–24.
Holmes, E. A., Grey, N., & Young, K. A. D. (2005). Intrusive images and
“hotspots”of trauma memories in posttraumatic stress disorder: an
exploratory investigation ofemotions and cognitive themes. Journal
of Behavior Therapy and Experimental Psychiatry, 36(1), 3–17.
Kane, M. T. (1982). A sampling model for validity. Applied
Psychological Measurement, 6,125–160.
Kane, M. T. (2001). Current concerns in validity theory. Journal of
Educational Measurement, 38,319–342.
Kubany, E. S., & Manke, F. P. (1995). Cognitive therapy for trauma-
related guilt: conceptual bases and treatment outlines. Cognitive and
Behavioural Practice, 2,27–61.
Kubany, E. S., & Watson, S. B. (2003). Guilt: elaboration of a multidi-
mensional model. Psychological Record, 53,51–90.
Kubany, E. S., Haynes, S. N., Abueg, F. R., Manke, F. P., Brennan, J. M.,
& Stahura, C. (1996). Development and Validation of the Trauma-
Related Guilt Inventory (TRGI).Psychological Assessment, 8,428–
444.
Lee, D. A. (2005). The perfect nurturer: A model to develop a compas-
sionate mind within the context of cognitive therapy. In P. Gilbert
(Ed.), Compassion: Conceptualisations, research and use in
psychotherapy (pp. 326–351). Hove, UK: Routledge.
Lee, D. A., Scragg, P., & Turner, S. (2001). The role of shame and
guilt in traumatic events: a clinical model of shame-based and
guilt-based PTSD. British Journal of Medical Psychology, 74,
451–466.
Leskela, J., Dieperink, M., & Thuras, P. (2002). Shame and posttraumatic
stress disorder. Journal of Traumatic Stress, 15,223–226.
Lewis, H. B. (1971). Shame and guilt in neurosis. Psychoanalytic Review,
58,419–438.
Lewis, M. (1995). Shame–the exposed self. New York: The Free Press.
Lindsay-Hartz, J. (1984). Contrasting experiences of shame and guilt.
American Behavioral Scientist, 27,689–704.
Macdonald, J., & Morley, I. (2001). Shame and non-disclosure: a study of
the emotional isolation of people referred to psychotherapy. British
JournalofMedicalPsychology,74,1–21.
Martens, W. (2005). A multicomponential model of shame. Journal for
theTheoryofSocialBehaviour,35,399–415.
Matos, M., & Pinto-Gouveia, J. (2010). Shame as a traumatic memory.
Clinical Psychology & Psychotherapy, 17,299
–312.
J Psychopathol Behav Assess
Messick. (1995). Standards of validity and the validity of standards in
performance asessment. Educational Measurement Issues and
Practice, 14,5–8.
Nathanson, D. L. (1987). The many faces of shame.NewYork:The
Guilford Press.
Neff, K. D. (2003). The development and validation of a scale to measure
self-compassion. Self and Identity, 2(3), 223–250.
Nunnally, J. C., & Bernstein, I. H. (1994). Psychometric theory (3rd ed.).
New York: McGraw-Hill.
Orth, U., Berking, M., & Burkhardt, S. (2006). Selfconscious emotions
and depression: rumination explains why shame but not guilt is
maladaptive. Personality and Social Psychology Bulletin, 32,
1608–1619.
Platt, M., & Freyd, J. (2012). Trauma and negative underlying assump-
tions in feelings of shame: anexploratory study. Psychological
Trauma Theory Research Practice and Policy, 4,370–378.
Power, M., & Dalgleish, T. (2008). Cognition and Emotion –From Order
to Disorder, second edition. Psychology Press.
Resick, P. A, & Schnicke, M. K. (1992). Cognitive processing therapy for
sexual assault victims. Journal of Consulting and Clinical
Psychology, 60(5), 748–56.
Resick, P. A., & Schnicke, M. K. (1993). Cognitive processing for rape
victims. Newbury Park: Sage.
Resick, P. A., Galovski, T. E., O’Brien Uhlmansiek, M., Scher, C. D.,
Clum, G. A., & Young-Xu, Y. (2008). A randomized clinical
trial to dismantle components of cognitive processing therapy
for posttraumatic stress disorder in female victims of interper-
sonal violence. Journal of Consulting and Clinical
Psychology, 76,243–258.
Santor, D. A., & Coyne, J. C. (1997). Shortening the CES–Dtoimprove
its ability to detect cases of depression. Psychological Assessment, 9,
233–243.
Semb, O., Strömsten, L. M., Sundbom, E., Fransson, P., & Henningsson,
M. (2011). Distress after a single violent crime: how shame-
proneness and event-related shame work together as risk factors
for post-victimization symptoms. Psychological Reports, 09,
3–23.
Shavelson, R. J., & Webb, N. M. (1991). Generalizability theory: A
primer. Newbury Park: Sage.
Shavelson, R. J., Webb, N. M., & Rowley, G. L. (1989). Generalizability
theory. American Psychologist, 44(6), 922–932.
Shrout, P. E., & Fleiss, J. L. (1979). Intraclass correlations: uses in
assessing rater reliability. Psychological Bulletin, 2,420–428.
Smith, G. T., McCarthy, D. M., & Anderson, K. G. (2000). On the sins of
short-form development. Psychological Assessment, 12,102
–111.
Smith, E. R., Duax, J. M., & Rauch, S. A. M. (2013). Perceived perpe-
tration during traumatic events: clinical suggestions from experts in
prolonged exposure therapy. Cognitive and Behavioral Practice, 20,
461–470.
Smucker, M. R., Grunert, B. K., & Weis, J. (2003). Posttraumatic Stress
Disorder: A New Algorithm Treatment Model. In R. L. Leahy (Ed.),
Overcoming roadblocks in cognitive therapy practice (pp. 175–
194). New York: Guilford Publications.
Spielberger, C. D., Gorsuch, R. L., & Lushene, R. E. (1970). STAI manual
for the state-trait anxiety inventory. Palo Alto: Consulting
Psychologists Press.
Steenkamp, M., Nash, W. P., Lebowitz, L., & Litz, B. T. (2013). Howbest
to treat deployment-related guilt and shame: commentary on Smith,
Duax, and Rauch (2013). Cognitive and Behavioral Practice, 20,
471–475.
Stone, A. M. (1992). The role of shame in post-traumatic stress disorder.
AmericanJournalofOrthopsychiathry,62,131–136.
Street, A. E., & Arias, I. (2001). Psychological abuse and posttraumatic
stress disorder in battered women. Examining the role of shame and
guilt. Violence and Victims, 16,65–78.
Tangney, J. P. (1991). Moral affect: the good, the bad and the ugly.
Journal of Personality and Social Psychology, 61,598–607.
Tangney, J. P., & Dearing, R. L. (2003). Shame & Guilt.NewYork:The
Guilford Press.
Tangney, J. P., Wagner, R., & Gramzov, R. (1989). The test of self-
conscious affect. Fairfax: George Mason University.
Tangney, J. P., Miller, R. S., Flicker, L., & Barlow, D. H. (1996). Are
shame, guilt and embarrassment distinct emotions? Journal of
Personality and Social Psychology, 70,1256–1269.
Tomkins, S. (1987). Shame. In D. L. Nathanson (Ed.), The many faces of
shame (pp. 133–161). New York: The Guilford Press.
Wicker, F. W., Payne, G. C., & Morgan, R. D. (1983). Participant
description of shame and guilt. Motivation and Emotion, 7,25–39.
Wilson, J. P., Drozdek, B., & Turkovic, S. (2006). Posttraumatic shame
and guilt. Trauma Violence and Abuse, 7,122–141.
Wong, M. R., & Cook, D. (1992). Shame and its contribution to PTSD.
Journal of Traumatic Stress, 5,557–562.
J Psychopathol Behav Assess
