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Avoidance Coping Partially Accounts for the Relationship
between Trauma-Related Shame and PTSD Symptoms following
Interpersonal Trauma
Jordyn M. Tipsword1, Jazmin L. Brown-Iannuzzi2, Alyssa C. Jones1, Jessica Flores1,
Christal L. Badour1
1University of Kentucky, Department of Psychology
2University of Virginia, Department of Psychology
Abstract
Research has demonstrated that individuals experiencing trauma-related shame exhibit greater
PTSD symptoms (e.g., La Bash & Papa, 2013). However, little research has investigated additional
factors relevant to the shame-PTSD relationship. The current study examined the role of avoidance
and approach coping in accounting for the trauma-related shame-PTSD association among 60
women who had experienced interpersonal trauma. Indirect effects tests revealed that avoidance
coping partially accounted for the association between shame and interviewer-assessed PTSD
symptoms,
β
= 0.21,
SE
= 0.08, 95% CI [0.03, 0.36]. These findings offer a novel contribution to
the growing literature examining negative outcomes following interpersonal trauma.
Posttraumatic Stress Disorder (PTSD) is an impairing psychological condition in which
individuals who have experienced trauma display several hallmark symptoms, including
re-experiencing the traumatic event, avoidance of stimuli that elicit reminders of the
traumatic experience, negative changes in cognition or affect, and alterations in arousal
and reactivity (American Psychiatric Association [APA], 2013). Although PTSD can result
from exposure to a variety of traumatic events, individuals with a history of interpersonal
trauma have been identified as being particularly at-risk for developing PTSD (Kessler,
Sonnega, Bromet, Hughes, & Nelson, 1995; Resnick, Kilpatrick, Dansky, Saunders, & Best,
1993).
Interpersonal trauma
broadly refers to acts that involve personal violation, assault,
and/or physical or sexual violence (Badour, Resnick, & Kilpatrick, 2017; Lilly & Valdez,
2012), including sexual assault, intimate partner violence, and physical assault, as well as
childhood sexual or physical abuse (Lilly & Valdez, 2012). Given that those with a history
of interpersonal trauma are particularly likely to develop PTSD as a result of that traumatic
experience, research has increasingly begun to investigate the nature and development of
PTSD among that population (e.g., Lilly & Valdez, 2012).
In particular, an expanding body of research has begun to investigate the interrelationships
between PTSD symptoms and specific negative emotions, such as anger, fear, guilt,
shame, disgust, and sadness (e.g., Hathaway, Boals, & Banks, 2010); however, our
current understanding of the mechanisms linking negative emotions to PTSD outcomes
is limited (La Bash & Papa, 2013). Whereas previous research often focused on the
relationship between fear and PTSD, recent research has been trending toward examining
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the relationship between other negative emotions and PTSD symptoms (e.g., Hathaway et
al., 2010) in an attempt to more fully understand the negative emotional consequences of
trauma.
Shame in particular tends to be prevalent among those who have experienced interpersonal
trauma (Badour et al., 2017) and may contribute a great deal to our understanding of PTSD
(Saraiya & Lopez-Castro, 2016). Shame has been conceptualized 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”
(Øktedalen, Hagtvet, Hoffart, Langkaas, & Smucker, 2014, p. 604). Previous research has
linked shame to a variety of negative outcomes, including aggression (Velotti, Elison, &
Garofalo, 2014), suicidal ideation (Bryan, Morrow, Etienne, & Ray-Sannerud, 2013), and
PTSD (La Bash & Papa, 2013; Saraiya & Lopez-Castro, 2016). Although existing studies
have investigated the factors linking other negative emotions – such as guilt (e.g., Held,
Owens, & Anderson, 2015) and anger (e.g., Olatunji, Ciesielski, & Tolin, 2010) – to PTSD
symptoms, the literature on trauma-related shame is less extensive in comparison. This is
especially noteworthy given that the experience of shame is relatively common following
exposure to interpersonal trauma (e.g., Badour et al., 2017; La Bash & Papa, 2013).
Given the aforementioned implications of shame for interpersonal trauma-related PTSD,
efforts to investigate it have increased in recent years (Saraiya & Lopez-Castro, 2016). These
recent investigations may have been motivated, in part, by changes in the conceptualization
of PTSD that emerged in the fifth edition of the
Diagnostic and Statistical Manual of Mental
Disorders
(
DSM
-5; APA, 2013; Badour et al., 2017). The
DSM-5
recognized a broader
range of emotional reactions to trauma than previous editions via the inclusion of PTSD
criterion D4, which involves persistent experiences of negative affect that arise or worsen
following traumatic events (e.g., fear, horror, anger, guilt, or shame; APA, 2013, p. 271).
With shame now appearing directly in the
DSM-5
criteria for PTSD, increased interest in the
link between trauma-related shame and PTSD has ensued.
Though shame has been linked to the emotional experience of guilt, research has sought
to disentangle the unique impact of trauma-related shame from that of trauma-related guilt
(e.g., Gilbert, 2003; Held et al., 2015; Leskela et al., 2002; Taylor, 2015), which refers to
a “self-conscious affect that relates to a sense of responsibility and the cause of harm to
others” (Lee, Scragg, & Turner, 2001, p. 456). Such studies have found that while trauma-
related guilt occurs as a result of feeling bad about particular actions or behaviors, trauma-
related shame involves more global negative attributions about the self (e.g., Lee et al., 2001;
Leskela et al., 2002). Furthermore, previous work has found that shame is a better predictor
of PTSD symptoms than is guilt (Bannister, Colvonen, Angkaw, & Norman, 2019). Thus,
shame can be characterized as a unique emotional response to trauma that, accordingly, may
contribute to negative trauma-related outcomes in unique ways. For example, some have
proposed that the experience of shame may lead to negative trauma-related outcomes by
encouraging individuals to either avoid stimuli that might trigger reminders of the trauma
or withdraw from previous responsibilities and relationships (Øktedalen et al., 2014; Saraiya
& Lopez-Castro, 2016). Others have emphasized that trauma-related shame may manifest
in the form of harsh self-judgment, including self-condemnation and self-scrutiny (e.g.,
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Lee et al., 2001). As such, additional research is needed to further clarify the nature of
trauma-related shame, including the thoughts and behaviors associated with it.
In addition, previous research has established that trauma-related shame, like other trauma-
related emotions, can either lessen in intensity or persist over time due to a variety of
factors, including deficits in emotion regulation (e.g., Villalta, Smith, Hickin, & Stringaris,
2018) and substance use (e.g., Holl et al., 2017; Ullman, Relyea, Peter-Hagene, & Vasquez,
2013). However, less research has empirically tested the factors that might influence the
relationship specifically between trauma-related shame and PTSD symptoms. Thus, the
present study aimed to evaluate whether specific coping strategies might account for the link
between trauma-related shame and PTSD symptom severity following interpersonal trauma.
One manner in which individuals who have experienced interpersonal trauma may attempt
to process that event and the negative emotional consequences of it is through the use of
coping strategies. Coping strategies refer to behavioral and cognitive techniques employed to
help an individual respond to stressors that are viewed as being overwhelming (Folkman &
Lazarus, 1988; Roth & Cohen, 1986). One common method of examining coping behavior
involves dividing potential strategies into two categories: approach coping and avoidance
coping (e.g., Tiet et al., 2006). Whereas
approach coping
involves focusing on addressing
the root causes of feelings of distress (e.g., seeking support from others, planning; Roth
& Cohen, 1986),
avoidance coping
involves diverting attention away from the problem or
event causing distress (Folkman & Lazarus, 1988; Tiet et al., 2006) through behaviors like
substance use or avoidance (Roth & Cohen, 1986). As such, persistent use of avoidance
coping has been associated with maladaptive outcomes.
Relatedly, research has consistently linked utilization of avoidance coping strategies with
more severe PTSD symptoms among those who have experienced interpersonal trauma (e.g.,
Krause, Kaltman, Goodman, & Dutton, 2008; Ullman et al., 2013). In contrast, use of
approach coping strategies has been linked to more effective social functioning and better
family relationships among individuals who have experienced trauma (Tiet et al., 2006),
as well as reduced PTSD symptoms (e.g., Hassija, Luterek, Naragon-Gainey, Moore, &
Simpson, 2012). In addition, preliminary research suggests that the use of avoidance coping
strategies may account, in part, for the relationship between specific negative emotions and
PTSD symptoms (e.g., Held et al., 2015; Street, Gibson, & Holohan, 2005). As Street and
colleagues (2005) affirm, such a finding suggests that the use of avoidance coping may be
a common method of responding to trauma because it helps individuals prevent or delay
negative emotional reactions that result from traumatic event exposure.
Though a great deal of existing research has highlighted the role of approach and avoidance
coping strategies in managing fear- or anxiety-related distress following stressful events
(e.g., Roth & Cohen, 1986; Walsh, Fortier, & DiLillo, 2010), it stands to reason that
coping may similarly serve as a means of managing other trauma-related negative emotions,
including trauma-related shame. Existing work has documented positive associations
between shame and avoidance coping both in trauma-exposed samples and non-trauma-
exposed samples and has posited that the intense distress associated with shame may elicit
avoidance behaviors that serve as a means of reducing short-term distress linked to shame
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(e.g., Harper, 2011; Van Vliet, 2010; Yi & Kanetkar, 2010). However, research has yet to
investigate the potential role of coping strategies in the relationship between trauma-related
shame and PTSD symptom severity in particular.
In the current study, it was hypothesized that trauma-related shame would be indirectly
linked to PTSD symptom severity via coping strategy utilization (approach vs. avoidance).
Specifically, it was expected that trauma-related shame would be associated with lower use
of approach coping strategies and higher use of avoidance coping strategies, and that use of
approach coping strategies would, in turn, be associated with less severe PTSD symptoms
whereas use of avoidance coping strategies would be associated with more severe PTSD
symptoms.
Method
Participants
Sixty women aged 18 to 66 (
M
age = 35.25 years,
SD
= 13.33) were recruited from the
community using paper and electronic flyers. All participants had experienced at least one
form of interpersonal trauma, defined here as an experience that occurred at any point
during the individual’s lifetime involving physical or sexual assault or abuse. An all-female
sample was recruited as women are more likely than men to experience certain forms of
interpersonal trauma (e.g., sexual trauma; Kessler et al., 1995; Kilpatrick et al., 2013) and
existing research has documented that women experience shame more frequently and/or
readily than men (Else-Quest, Higgins, Allison, & Morton, 2012; Lutwak & Ferrari, 1996).
Those who responded to advertisements but did not report a form of interpersonal trauma
as their primary traumatic experience were excluded from the study. In addition, individuals
who indicated they had experienced interpersonal violence within the previous 30 days were
required to delay participation until at least one month had elapsed following that experience
to ensure that we were evaluating posttraumatic experiences rather than acute trauma-related
distress.
Participants identified as 66.7% White, 23.3% African American, 3.3% Multiracial, 1.7%
Native Hawaiian/Pacific Islander, 1.7% Asian, 1.7% American Indian/Alaska Native, and
1.7% of participants reported belonging to another racial group. Four participants (6.7%)
identified as Hispanic. Participants’ incomes ranged from <$20,000 to >$100,000 and
the most frequently reported household income was < $20,000 (36.7%). In addition, all
participants reported having completed at least some education beyond high school. Within
our sample, 16.7% of participants were college graduates and 18.3% had completed either
graduate or professional school.
Approximately 16.7% of our sample reported having experienced a single form of physical
or sexual trauma, while the remaining 83.3% reported having experienced multiple forms.
The mean age at which participants experienced the index – or most distressing –
interpersonal trauma event was 17.98 years (
SD
= 7.93). Participants endorsed having
experienced the following forms of physical and sexual trauma: having intercourse or
engaging in oral or anal sex against their will (73.3%); being forced to touch the private
parts of another individual or being forcibly touched by another individual (73.3%); being
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in a situation involving attempted forcible and unwanted sexual contact (53.3%); being
attacked with a weapon (40.0%); being injured by an attack without a weapon (35.0%);
and being beaten, spanked, or pushed to the point of injury (45.0%). Additionally, 50.0%
(
n
= 30) of participants met criteria for a current diagnosis of PTSD based on the Clinician-
Administered PTSD Scale for
DSM-5
(CAPS-5; Weathers et al., 2013a).
Measures
Trauma history.—History of interpersonal trauma was assessed via the Physical and
Sexual Experiences subscale of the Trauma History Questionnaire (THQ; Green, 1996).
Sample items on this six-item subscale include “Has anyone ever made you have intercourse
or oral or anal sex against your will?” and “Has anyone in your family ever beaten,
spanked, or pushed you hard enough to cause injury?” For each event, participants indicated
whether they had ever experienced it (
yes
or
no
). For each item to which they responded
affirmatively, participants were asked how many times and at approximately what age(s)
they had experienced that event. The THQ has demonstrated satisfactory interrater reliability
(kappas .57 – .76) and test-retest reliability (stability coefficients over 2–3 months ranging
from .51 to .91; Hooper, Stockton, Krupnick, & Green, 2011).
PTSD symptoms.—Symptoms of PTSD were assessed via the PTSD Checklist for
DSM-5
(PCL-5; Weathers et al., 2013b) and the Clinician-Administered PTSD Scale for
DSM-5
(CAPS-5; Weathers et al., 2013a) to provide for both self-report and interviewer-
evaluated past-month PTSD symptoms, respectively. The PCL-5 is a 20-item self-report
measure of PTSD that provides information concerning both the frequency and overall
severity of PTSD symptoms. For each item, participants indicated the extent to which the
described behavior or experience bothered them during the past month using a Likert-type
scale (0 =
Not at all
to 4 =
Extremely
). A total score for the PCL-5 was calculated for
each participant by summing scores for all scale items. Missing data for one PCL-5 item
for one participant was determined to be missing at random and was therefore imputed
using expectation-maximization procedures. The PCL-5 has exhibited strong reliability in
both initial tests of its psychometric properties (
α
= .94; Blevins, Weathers, Davis, Witte, &
Domino, 2015) and in the present sample (
α
= .96).
The CAPS-5 is a semi-structured clinical interview designed to evaluate frequency and
intensity of 20 DSM-5 PTSD symptoms over the past month. Each item is rated on a
five-point scale (0 =
Absent
to 4 =
Extreme / incapacitating
). The CAPS-5 exhibits strong
reliability and validity (e.g., Weathers et al., 2018) and is a well-established measure of
PTSD symptoms. Internal consistency in the present study was excellent (
α
= .90). A
graduate researcher trained in the CAPS-5 conducted all participant interviews, and 20% of
interviews were randomly selected and coded for interrater reliability using Cohen’s Kappa
for diagnostic reliability (κ = 1.0) and two-way mixed, absolute, single-measures ICCs for
reliability in individual symptom severity ratings (ICCs: .92 – 1.0; Hallgren, 2012). A total
symptom severity score for the CAPS-5 was calculated using the same procedures utilized
for the PCL-5. PTSD diagnostic status was also computed based on the SEV2 scoring rule
for determining symptom counts within each criterion (Weathers et al., 2018).
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Trauma-related shame.—Trauma-related shame was assessed via responses to the
Trauma-Related Shame Inventory (TRSI; Øktedalen et al., 2014), which is a 24-item self-
report measure designed to evaluate the presence and severity of shame linked to traumatic
experiences. Participants identified the extent to which each statement applied to them using
a Likert-type scale (0 =
Not true of me
to 3 =
Completely true of me
). Scores for all items
were then summed to create a total index of trauma-related shame for each participant,
wherein higher total scores indicated greater levels of shame. The TRSI has demonstrated
satisfactory reliability and validity in previous research (e.g., Øktedalen et al., 2014) and
exhibited strong reliability within our sample (
α
= .97).
Approach and avoidance coping.—A modified version of the Brief COPE (Carver,
1997) was used to assess approach and avoidance coping in response to the index trauma.
Items on the Brief COPE are designed to correspond to one of fourteen coping subscales.
In line with previous research using the Brief COPE to investigate approach and avoidance
coping (e.g., MacAulay & Cohen, 2013), we defined approach strategies as those that
comprised the planning and active coping subscales (four items total), and avoidance
strategies as those that comprised the denial and behavioral disengagement subscales (four
items total). Additional research has also utilized the eight selected items within broader
scales measuring approach and/or avoidance coping behavior, lending support to their use
for this purpose (e.g., Schnider, Elhai, & Gray, 2007; Snell, Siegert, Hay-Smith, & Surgenor,
2011). Together, the four subscales corresponded to eight total coping-related items – four
assessing approach coping strategy use and four assessing avoidance coping strategy use.
For each item, participants indicated how often they had engaged in the described behavior
using a Likert-type scale (1 =
I haven’t been doing this at all
to 4 =
I’ve been doing this a
lot
). Overall scores for approach and avoidance coping were calculated for each participant
by summing responses to selected items, with lower scores indicating less frequent use of
each type of coping. Cronbach’s alpha values for the approach (
α
= .80) and avoidance
coping subscales (
α
= .70) in our study suggested moderate and satisfactory reliability,
respectively.
Procedure
Women with a history of interpersonal trauma were recruited as part of a larger study
focused on understanding emotional experiences and emotion regulation in the context of
interpersonal trauma. Women who contacted the lead researcher were then screened over
the phone to assess whether they met the study eligibility criteria. Those who met criteria
completed an online questionnaire battery and were then asked to attend two laboratory
visits to complete interviews, self-report measures, and a laboratory task not relevant to
the current investigation. Participants also completed two weeks of daily diary assessments.
Data for the current investigation were all collected from baseline measures completed
online through the survey platform Qualtrics prior to (PCL-5) or during (CAPS-5, TRSI, and
Brief COPE) the laboratory visits; the present study did not utilize any data from daily diary
assessments. Participants provided online consent prior to completing the baseline measures
and written informed consent at the first laboratory session. All participants were debriefed
after completing the study. Participants received $30 for each laboratory visit and could earn
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a maximum total of $160 if they chose to participate in all parts of the study. Data collection
was approved by the university’s Institutional Review Board (IRB).
Data Analytic Plan
First, descriptive statistics and zero-order correlations were examined. Separate indirect
effects models were then conducted in SPSS 26 using the PROCESS custom dialog (Hayes,
2013) to test the hypotheses that trauma-related shame would positively relate to: a) self-
reported and b) interviewer-assessed PTSD symptom severity via avoidance coping and
negatively relate via approach coping. As assessments of trauma-related shame (TRSI) and
coping (Brief COPE) were administered during the same in-lab visit, temporal precedence
was unable to be established for those variables; thus, both indirect effects models were
cross-sectional. Both unstandardized and standardized (
M
= 0;
SD
= 1) path coefficients
were examined to aid in interpretation. A bias-corrected (BC) 95% confidence interval (CI)
was used as the criterion for evaluating significance of the indirect effects. Indirect effects
were considered statistically significant if zero was not included in the 95% CI generated
based on the established sampling distribution. Bootstrapping with 5000 resamples was
employed to assess for the presence of indirect effects, as well as to contrast the size of
individual indirect effects (Hayes, 2009; Williams & MacKinnon, 2008). Additional models
were evaluated using age at index trauma and whether participants experienced single vs.
multiple experiences of interpersonal trauma as covariates. Inclusion of these covariates did
not change the primary results of the process models described below.
Results
Descriptive Statistics and Zero-Order Correlations
Descriptive statistics and zero-order correlations are presented in Table 1. Overall,
participants reported using approach coping strategies more often than avoidance coping
strategies. Furthermore, the mean PCL-5 PTSD symptom severity score among our sample
was 32.57 (
SD
= 20.20), which corresponds to borderline clinically significant symptoms
based on recommended clinical cut-point scores ranging from 31 to 38 in recent research
(e.g., Bovin et al., 2016; Hoge et al., 2014; Wortmann et al., 2016).The mean CAPS-5 PTSD
symptom severity score was 21.77 (
SD
= 12.93), which corresponds to mild to moderate
PTSD symptom severities based on recommended score ranges for the CAPS-5 (Weathers et
al., 2018).
At the zero-order level, avoidance coping was positively correlated with trauma-related
shame and both self-reported and interviewer-assessed PTSD symptoms. Contrary to
hypotheses, approach coping was also positively correlated with trauma-related shame and
self-reported (but not interviewer-assessed) PTSD symptom severity. As expected, trauma-
related shame was also positively correlated with both self-reported and interviewer-assessed
PTSD symptoms.
Primary Analyses
Results from the first model predicting interviewer-assessed PTSD symptoms via the
CAPS-5 (Weathers et al., 2013a) are displayed in Figure 1. As expected, trauma-related
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shame was positively related to avoidance coping (
Path A
1). Contrary to hypotheses, trauma-
related shame was also positively related to approach coping (
Path A
2). After accounting for
trauma-related shame, avoidance coping was also positively related to interviewer-assessed
PTSD symptoms (
Path B1
), but the association with approach coping was not significant
(
Path B2
). As expected, indirect effects tests revealed that the pathway from trauma-related
shame to interviewer-assessed PTSD symptoms was significant via avoidance coping,
Path
AB1: B =
0.15,
SE
= 0.07, 95% CI [0.02, 0.29];
β
= 0.21. The non-significant
B2
path
precluded a test of the
AB2
indirect effect.
Results from the second model predicting self-reported PTSD symptoms via the PCL-5
(Weathers et al., 2013b) are displayed in Figure 2. Similar to the first model, trauma-related
shame was positively related to both avoidance coping (
Path A
1) and approach coping (
Path
A
2). However, after accounting for trauma-related shame we failed to detect significant
associations between avoidance coping (
Path B1
) or approach coping (
Path B2
) and self-
reported PTSD symptom severity. As such, indirect effects tests were not conducted for this
model.
Discussion
The present study investigated whether coping strategy utilization accounted for the
relationship between trauma-related shame and PTSD symptoms among a sample of women
with a history of interpersonal trauma. In line with previous research (e.g., Leskela et al.,
2002; Stone, 1992), we hypothesized that trauma-related shame would be associated with
greater PTSD symptom severity, more frequent use of avoidance coping strategies, and less
frequent use of approach strategies. It was further hypothesized that elevated use of approach
coping strategies would, in turn, be associated with less severe PTSD symptoms, whereas
elevated use of avoidance coping strategies would be associated with more severe PTSD
symptoms. Our proposed model was partially supported, with elevated use of avoidance
coping strategies partially explaining the relationship between trauma-related shame and
severity of interviewer-assessed (but not self-reported) symptoms of PTSD.
Consistent with both our hypotheses and previous research (e.g., Leskela et al., 2002; Stone,
1992; Wilson, Droždek, & Turkovic, 2006), we found a strong positive association between
trauma-related shame and PTSD symptom severity, wherein those who experienced greater
levels of shame also tended to experience more severe PTSD symptoms. This relationship
remained significant even when controlling for age at which the index traumatic event
occurred and whether participants had experienced a single incident or multiple incidents
involving interpersonal trauma. These results converge with the growing body of work
documenting a consistent link between trauma-related shame and elevated PTSD symptoms.
Additionally, we found that trauma-related shame was linked to greater coping efforts
involving both avoidance and approach strategies. Although this finding was anticipated for
avoidance coping, results revealing a positive association between trauma-related shame and
approach coping were contrary to our hypotheses. This is surprising given the substantial
literature linking trauma-related shame to a tendency to engage in avoidance coping
behaviors over approach coping behaviors (e.g., Held et al., 2015). However, there are
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several potential explanations for such a finding. First, it cannot be said that individuals
in our sample were engaging in approach coping in instances in which they were actively
experiencing trauma-related shame. Thus, it is possible that although shame and approach
coping were positively associated with one another, participants may have been utilizing
those approach strategies to manage other negative trauma-related experiences (e.g., PTSD
symptoms) instead of employing them to manage trauma-related shame in particular. In
addition, the finding that use of approach coping was not significantly associated with fewer
PTSD symptoms also suggests that although individuals in our sample were engaging in
approach coping behaviors, those behaviors may not have been effective in reducing PTSD
symptoms. Such a conclusion is supported by recent work demonstrating that the processes
by which individuals a) select strategies to employ in the management of negative emotion
and b) effectively implement those strategies are separate from one another (Kalokerinos,
Erbas, Ceulemans, & Kuppens, 2019). As such, it is possible that individuals experiencing
high levels of trauma-related shame may utilize approach coping strategies, but may do
so in ineffective ways. In such cases, we might fail to see reductions in PTSD symptoms
following approach coping behaviors, as occurred in our findings.
Our findings concerning the relationship between trauma-related shame and coping
behaviors are also noteworthy given that much work in the coping literature has focused
on avoidance coping, considering this to be an index of unhelpful or maladaptive coping
strategies (e.g., Krause et al., 2008). However, as our findings highlight, individuals may
engage in a variety of coping strategies in response to trauma-related distress. Thus, it
is important to consider both avoidance strategies and approach strategies when aiming
to evaluate the range of coping behaviors an individual may employ. Furthermore, it is
also worth noting that the context surrounding coping behavior may also influence the
adaptiveness of a given coping strategy (e.g., Aldao, 2013). For example, coping behaviors
that are often deemed maladaptive (e.g., distraction) might prove useful and, in fact, improve
an individual’s ability to function in certain situations (e.g., when fulfilling employment
responsibilities). As such, it is important to consider the full context within which an
individual is functioning when assessing and evaluating the coping behaviors that individual
is employing.
In addition, our hypothesis that avoidance coping would partially account for the association
between trauma-related shame and PTSD symptoms was supported for interviewer-assessed
(but not self-reported) PTSD symptoms. This finding for interviewer-assessed PTSD
symptoms aligns well with previous research linking maladaptive coping to adverse
outcomes among those experiencing negative trauma-related emotions (e.g., Held et al.,
2015). It is worth noting, however, that findings were not consistent with hypotheses when
examining self-reported PTSD symptoms. Although use of avoidance coping strategies was
positively associated with both interviewer-assessed and self-reported PTSD symptoms at
the zero-order level, the association between avoidance coping and self-reported PTSD
symptoms failed to reach significance when accounting for trauma-related shame. Further
discussion of this discrepancy is warranted. First, it may be the case that the association
failed to reach significance after controlling for trauma-related shame due to the relative
strength of the correlation between trauma-related shame and self-reported PTSD symptom
severity (
r
= .68). In addition, it could be the case that individuals experiencing trauma-
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related shame may have difficulty distinguishing between distress associated with trauma-
related shame and more general distress associated with PTSD symptoms. Indeed, it has
been established that both the experience of PTSD and the experience of trauma-related
shame involve a great deal of general distress (e.g., La Bash & Papa, 2013; Resnick et al.,
1993), which may further complicate the process of parsing apart distress associated with
each individual experience.
Finally, it should be noted that the CAPS-5 is widely considered to be the most valid and
reliable measure of PTSD symptoms due to its strong psychometric properties and direct
correspondence to all 20
DSM-5
PTSD symptoms (e.g., Geier, Hunt, Nelson, Brasel, &
deRoon-Cassini, 2019; Weathers et al., 2018). Although the PCL-5 has been established as
a useful measure to utilize when administering the CAPS-5 is unfeasible or inappropriate
(e.g., Geier et al., 2019), the CAPS-5 remains the most optimal measure of PTSD symptoms.
As a result, findings based on CAPS-5 scores should be weighed more heavily than those
based on self-reported PTSD symptom scores, including PCL-5 scores.
In contrast with avoidance coping, we failed to find any support for the hypothesis that
approach coping would partially account for the trauma-related shame-PTSD relationship.
Although approach coping was positively correlated with trauma-related shame and self-
reported PTSD symptoms at the zero-order level, approach coping was not significantly
related to either interviewer-assessed or self-reported PTSD symptoms after accounting for
the effects of trauma-related shame. This finding was surprising given that previous research
has documented a significant negative correlation between use of approach coping strategies
and PTSD symptom severity (e.g., Hassija et al., 2012). However, as previously outlined,
this discrepancy in findings could be explained by the strong correlation between shame and
PTSD symptom severity in our sample, as well as the overlap between distress associated
with trauma-related shame and distress associated with PTSD symptoms more broadly.
An additional explanation for these findings diverging from previous research could be
that our study focused exclusively on
problem-focused
methods of approach coping, which
involve behavioral approaches to addressing a particular traumatic event (e.g., “I’ve been
taking action to try to make the situation better”; Carver, 1997). Although this approach was
chosen in alignment with previous research on approach coping, the scope of the methods
examined may have been too narrow. In contrast with our approach, existing work on
emotional responses to trauma has either focused on
emotion-focused
methods of approach
coping, such as open emotional expression (e.g., Hassija et al., 2012), or a combination
of problem-focused and emotion-focused coping methods (e.g., Held et al., 2015). This
divergence is potentially significant given that approach coping is generally thought to
encompass
both
problem-focused and emotion-focused coping strategies (Folkman &
Lazarus, 1988). Based on that framework, our definition of approach coping was limited
in that it only included a portion of all the possible means of approach coping. Although
this method of measuring approach coping has been utilized widely in other studies, it
may have limited both our ability to fully assess the impact of approach coping and the
robustness of its associations with other model variables. This is especially significant
given that emotion-focused coping would likely be particularly relevant to the affective
experience of trauma-related shame. Further research assessing both problem-focused and
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emotion-focused methods of coping is needed before conclusions concerning the role of
approach coping in the shame-PTSD relationship can be drawn.
Although our findings offer a novel contribution to the literature on trauma-related shame
and PTSD symptom severity, our study is not without limitations. Perhaps most importantly,
our data were cross-sectional in nature, which precludes conclusions concerning temporality
or causality in our model. As such, it is possible that the sequential order put forth in
our model is correct in concluding that trauma-related shame leads to increased avoidance
coping, which in turn leads to more severe PTSD symptoms; however, it remains possible
that PTSD symptoms may lead to increased avoidance coping, which may, in turn, lead
to greater levels of trauma-related shame. Future research employing a prospective design
would be necessary to more fully understand the temporal order – and potentially the context
– of these variables.
In addition, participants in our sample endorsed relatively low utilization of both approach
and avoidance coping strategies relative to the possible range of values on the Brief COPE
(Carver, 1997). Although we found significant correlations between both approach and
avoidance coping and PTSD symptoms, use of avoidance coping strategies was particularly
low, with the mean avoidance coping score falling short of the scale point corresponding to
using avoidance strategies “a little bit” (Carver, 1997). Given extensive previous research
documenting a strong association between experience with interpersonal trauma and greater
use of avoidance coping methods (e.g., Krause et al., 2008; Ullman et al., 2013), the
relatively low endorsement of avoidance coping among our sample is noteworthy. Although
the reasons for this discrepancy remain unclear, it is possible that the low avoidance coping
exhibited within our sample may be reflective of the types of coping assessed. For example,
participants may have, in fact, been utilizing more avoidance coping strategies that were
simply not assessed in the present study. Alternatively, it is possible that our sample
simply utilized fewer avoidance coping techniques than the samples assessed in previous
research or underreported their use of these strategies due to the retrospective nature of their
reports (e.g., Stone et al., 1998). Additionally, it should be noted that little research has
directly evaluated the utility of the Brief COPE in assessing approach and avoidance coping
specifically, limiting knowledge concerning the psychometric properties of the Brief COPE
when implemented for this purpose. Though the present study contributes to the limited
literature using the Brief COPE to evaluate approach and avoidance coping, future work may
benefit from utilizing measures that have better established psychometric properties when
examining approach and avoidance coping specifically (e.g., Coping Strategies Inventory
[Tobin, Holroyd, Reynolds, & Wigal, 1989], Ways of Coping Checklist [Vitaliano, Russo,
Carr, Maiuro, & Becker, 1985]). Finally, it is not clear whether these findings would
generalize to other trauma-exposed populations as the study at hand specifically recruited
individuals with a history of interpersonal trauma. As a result, further research would be
warranted to determine whether our findings generalize to a broader range of individuals
exposed to trauma.
In spite of its limitations, the present study has several potential clinical implications.
First, our findings suggest that interventions addressing PTSD symptoms among those
experiencing trauma-related shame might benefit from targeting and reducing avoidance
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behaviors; however, these findings would need to be investigated prospectively before such a
conclusion can be more substantially supported. Furthermore, these findings underscore the
importance of evaluating and monitoring negative affect – in this case, trauma-related shame
– in clinical settings when treating those who have experienced interpersonal trauma.
Taken together, our findings provide preliminary support for the notion that avoidance
coping partially accounts for the association between trauma-related shame and PTSD
symptoms among those with a history of interpersonal trauma. Such a finding is particularly
significant given that very little is presently known about the factors that might be
contributing to the shame-PTSD association, and no known previous work had examined
the role of coping specifically in the shame-PTSD relationship. As a result, these findings
contribute to a growing body of literature evaluating the role of shame in relation to negative
trauma-related outcomes.
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Figure 1.
Results of the indirect effects model predicting clinician-evaluated PTSD symptoms from
trauma-related shame via avoidance and approach coping. Unstandardized coefficients and
corresponding standard errors are presented with standardized coefficients included in
parentheses to aid in interpretation.
*
p
< .05. **
p
< .01.
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Figure 2.
Results of the indirect effects model predicting self-reported PTSD symptoms from
trauma-related shame via avoidance and approach coping. Unstandardized coefficients
and corresponding standard errors are presented with standardized coefficients included in
parentheses to aid in interpretation.
*
p
< .05. **
p
< .01.
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Author Manuscript Author Manuscript Author Manuscript Author Manuscript
Tipsword et al. Page 18
Table 1
Descriptive Data and Zero-Order Correlations for All Model Variables
Variable 1 2 3 4 5 M (SD) Range
1. Trauma-related shame (TRSI) - .32
*
.59
**
.68
**
.60
**
22.22 (18.04) 0–84
2. Approach coping (Brief COPE) - - .22 .36
**
.08 8.83 (3.33) 4–16
3. Avoidance coping (Brief COPE) - - - .53
**
.58
**
6.05 (2.38) 4–16
4. PTSD Symptom Severity (PCL-5) - - - - .67
**
32.57 (20.20) 0–80
5. PTSD Symptom Severity (CAPS-5) - - - - - 21.77 (12.93) 0–80
CAPS-5
Clinician-Administered PTSD Scale for
DSM-5, PCL-5
PTSD Checklist for
DSM-5
,
TRSI
Trauma-Related Shame Inventory
Note.
*p
< .05
** p
< .01
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