Garland, Anne
(2022)
The role of shame, self-criticism and self-compassion in persistent, treatment resistant depression.
PhD thesis, University of Nottingham.
Abstract
Background
In 2017 the World Health Organisation (WHO), declared depression to be the leading cause of disability adjusted life years lost due to ill-health. Further, it is well established in the research literature that depression is a relapsing illness. In using Cognitive -Behavioural Therapy (CBT) with patients diagnosed with persistent, treatment resistant depression two clinical observations underpin this thesis. Firstly, that shame and self-criticism are key features of depression and secondly that standard Beckian CBT interventions have limited impact in tackling shame and self-criticism in this patient group. Integrating Compassion Focused Therapy (CFT) with CBT interventions results in some amelioration of shame and self-criticism, but this is limited empirically.
Aim
To examine shame, self-criticism and self-compassion in persistent, treatment resistant depression using the framework of Gilbert’s evolutionary psycho-biosocial formulation of emotional disorders.
Methods
Using a convergent parallel mixed methods design, the present study investigated the psychometric properties of three measures: the Other as Shamer Scale (OAS), Forms of Self-Criticism and Self-Reassurance Scale (FSCSR) and the Self-Compassion Scale (SCS) in a sample recruited from a large National Institute for Health Research (NIHR) funded Randomised Controlled Trial (RCT). Internal consistency and test-retest reliability were assessed, and construct validity examined with Confirmatory Factor Analysis (CFA). Univariate and multivariate statistical analysis was conducted to test the degree to which levels of shame, self-criticism and self-compassion varied according to level of depression as measured on three well validated measures of depression. In addition, using semi-structured interviews, a subset of participants (n=10) from the Treatment as Usual Arm (TAU) of the RCT cohort were interviewed to explore their lived experience of depression, shame, self-criticism and self-compassion. Interview data was analysed using Interpretative Phenomenological Analysis
(IPA).
Findings
The OAS and FSCSR were found to be both reliable and valid measures when administered to this cohort. The descriptive goodness of fit indices and CFA supported the three-factor model (inferior, emptiness, mistakes) of external shame in the OAS and the three-factor (inadequate self, hated self, reassured self) model of internal shame in the FSCSR. The qualitative data provided evidence to support this conclusion. However, in the OAS the sub-scale emptiness did not perform as well as the inferior and mistakes sub-scales. This was also reflected in the qualitative data with no respondent speaking about emptiness as formulated within the OAS, but rather speaking about worthlessness as an aspect of external shame. Meanwhile, whilst the SCS demonstrated reliability it did not prove to be a valid measure in the cohort under study. The descriptive goodness of fit indices supported the six-factor model proposed by the SCS but the measure showed poor discriminant validity, due to issues of multicollinearity. In addition, the qualitative data analysis suggested the negative sub-scales of the SCS (self-judgement, isolation and overidentification) appeared to tap directly into the psychopathology of depression. An unexpected finding in the quantitative data analysis was that levels of shame and self-criticism did not appear to be a function of severity of depression but appear to be more stable psychological constructs. However, the qualitative data contradicted this. Both forms of data collected in this thesis highlight the importance of attribution in depression and shame. The qualitative analysis yielded interesting data regarding the relationship between different childhood environments and the different forms of external and internal shame.
Conclusion
The OAS (a measure of external shame) and the FSCSR (a measure of internal shame) are reliable and valid measures when tested on a cohort with persistent, treatment resistant depression. Further, both the quantitative and qualitative results provided evidence to support the formulation of shame tested in this thesis, and the presence of an interrelated, but differentiated relationship between external and internal shame in this population. A model is proposed which integrates attributional theories of depression and shame, and an evolutionary psychobiosocial perspective, which takes into consideration the cognitive science of depression, specifically, the presence of intrusive, autobiographical, shame based emotional memories in depression and the role of rumination, thought suppression and dissociation, as affect regulation strategies. These memories, linked to childhood trauma, are important in the maintenance of persistent, treatment resistant depression. This study extends clinical knowledge of the phenomenology of shame, self-criticism and self-compassion in the population studied.
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