Suicide and Life-Threatening Behavior 44 (3) June 2014 © 2013 The American Association of Suicidology DOI: 10.1111/sltb.12069

317

The Effect of Shame-Proneness, Guilt-Proneness, and Internalizing Tendencies on Nonsuicidal Self-Injury SUSAN VANDERHEI, MA, JOHANNES ROJAHN, PHD, JEFFREY STUEWIG, PHD, PATRICK E. MCKNIGHT, PHD

AND

Nonsuicidal self-injury is especially common in adolescents and young adults. Self-injury may be related to shame or guilt—two moral emotions—as these differentially predict other maladaptive behaviors. Using a college sample, we examined not only how shame-proneness, guilt-proneness, and internalizing emotional tendencies related to self-injury, but also whether these moral emotions moderate the relation between internalizing tendencies and self-injury. High shame-proneness was associated with higher frequencies of self-injury. High guilt-proneness was associated with less self-injury, although this effect was mitigated at higher levels of internalizing tendencies. These results suggest shame-proneness is a risk factor for self-injury, while guiltproneness is protective. Nonsuicidal self-injury (NSSI) is the direct, intentional destruction of one’s own body tissue without suicidal intent (Nock & Favazza, 2009). Nonsuicidal self-injury includes behaviors such as cutting, burning, scratching, banging, hitting, biting, and interfering with wound healing (Klonsky, 2011), but is distinct from other types of culturally sancSUSAN VANDERHEI, Department of Psychology, University of Pittsburgh, Pittsburgh, PA, USA; JOHANNES ROJAHN, JEFFREY STUEWIG, and PATRICK E. MCKNIGHT Department of Psychology, George Mason University, Fairfax, VA, USA. The authors would like to thank Lisa Meier, Sarah Waldron, Tamra Rich, and Kiara Elkin for their assistance in conceptualizing and conducting this study. We are grateful for the invaluable assistance of Kathryn Monahan, Jennifer Silk, Danny Shaw, and Simone Lawrence, as well as the students who participated in our study. This study was conducted as partial fulfillment of the requirement for the Masters of Art degree by the first author. Address correspondence to Susan VanDerhei, Department of Psychology, University of Pittsburgh, Pittsburgh, PA 15260; E-mail: [email protected]

tioned self-directed harm, such as alcohol and nicotine consumption, getting tattooed or pierced, and overeating (Favazza, 1996). Engaging in NSSI is not only an immediate physical risk, but also may increase the likelihood of attempted and completed suicide (Andover & Gibb, 2010; Asarnow et al., 2011; Joiner, 2005). The Centers for Disease Control (2008) reported an increasing trend in NSSI over the past 10 to 20 years, a pattern bolstered by a rise in anecdotal evidence from teachers, clinicians, and other health professionals (Nock, 2010). Empirical studies report the prevalence of NSSI is relatively high in college samples, with an estimated prevalence between 14% and 38% (Favazza, 1996; Gratz, 2006; Gratz, Conrad, & Roemer, 2002), as compared to adolescents (13%–21%; Ross & Heath, 2002) and adults (4%; Briere & Gil, 1998). Although considerable research has been devoted to examining the correlates and predictors of NSSI, there is still little consensus in the field regarding why some people choose to intentionally hurt themselves (Nock, 2010).

318

MORAL EMOTIONS, INTERNALIZING TENDENCIES,

Those who engage in NSSI have reported doing so for automatic reasons (e.g., intrapersonal emotion regulation, or “to stop bad feelings”), social reasons (e.g., interpersonal avoidance or escape, or to “get a reaction from someone”), or both (LloydRichardson, Perrine, Dierker, & Kelley, 2007; Nock & Prinstein, 2004). Although research in recent years has brought us closer to understanding the motivations behind this complex behavior, much is still unknown. In the study presented here, we attempted to identify the interplay of psychological and emotional risk factors that may lead to NSSI onset and maintenance, in a college sample. Two known risk factors for NSSI are anxiety (Chartrand, Sareen, Toews, & Bolton, 2012) and depression (Jacobson & Gould, 2007; Klonsky & Olino, 2008; Muehlenkamp & Gutierrez, 2007). Specifically, more pronounced symptoms of depression and anxiety (along with increased rumination) have been reported by college students with a self-reported history of NSSI versus those without this history (Hoff & Muehlenkamp, 2009). Although the effect of different forms of psychopathologies on the presence of NSSI has been studied extensively in recent years (e.g., Nock, Wedig, Holmberg, & Hooley, 2008), no research to date has explored the role of social or moral emotions in the development and maintenance of NSSI. These “self-conscious” moral emotions result from an individual’s evaluation of his or her self (Eisenberg, 2000), which make them likely contributors to the onset and escalation of NSSI. Specifically, shame and guilt are two negative and distinct emotions that influence both internalizing and externalizing behaviors (Stuewig & Tangney, 2007; Tangney, Stuewig, & Mashek, 2007). Although the terms shame and guilt are often used interchangeably, research suggests important conceptual differences between the two (Tangney et al., 2007). While both deal with self-evaluative judgments, they differ on the focus of this evaluation. Specifically, Lewis (1971) theorized

AND

NSSI

that the key difference is whether one attributes failures to “the self” or to one’s “behavior.” On the one hand, shame results from a negative evaluation of the entire self. Guilt, on the other hand, implies negative evaluations of one’s behavior. Furthermore, these two emotions lead to different “action tendencies.” Shame is typically associated with tendencies to hide or escape from negative feelings and situations (Lindsay-Hartz, 1984), because a person’s self-evaluation has led them to believe they are fundamentally flawed. Conversely, guilt seems to be a more adaptive moral emotion, in that people who are guilt-prone tend to address problems directly and more appropriately. When a person is guilt-prone, as opposed to shame-prone, they typically are able to isolate the evaluation of their specific undesirable behavior without generalizing negative evaluations to himself or herself as a whole. Shame-proneness and guilt-proneness also tend to have differential relations with a host of outcomes. Shame-proneness is consistently positively associated with a variety of internalizing symptoms (Tangney, Wagner, & Gramzow, 1992), including depression (Stuewig & McCloskey, 2005), social and generalized anxiety (Fergus, Valentiner, McGrath, & Jencius, 2010), and eating disorders (Goss & Allan, 2009). A variety of externalizing and risky behaviors have also been linked to shame-proneness, such as anger (Tangney, Wagner, Fletcher, & Gramzow, 1992; Tangney, Wagner, Hill-Barlow, Marschall, & Gramzow, 1996), substance use (Dearing, Stuewig, & Tangney, 2005), and criminal offending (Wright, Gudjonsson, & Young, 2008). In contrast, guilt-proneness is largely unrelated or negatively related to the aforementioned internalizing and externalizing dimensions associated with shame-proneness (Stuewig, Tangney, Heigel, Harty, & McCloskey, 2010; Tangney & Dearing, 2002). Guilt-proneness is associated with good social adjustment (Eisenberg, 2000), and “other-oriented” empathy (Tangney, 1991). The other-oriented empathic con-

VANDERHEI

ET AL.

cern elicited by guilt-proneness is believed to promote prosocial behavior and help in the maintenance of close interpersonal relationships. Although much research has investigated shame and guilt, very little of it has applied these constructs to NSSI. In their review of suicidal research, Hastings, Northman, and Tangney (2000) conclude that shame should be a greater predictor of suicidality than guilt. Using data from two different samples of undergraduate students, they found shame-proneness was positively related to suicide ideation, while guilt-proneness, when controlling for shame, was generally unrelated or slightly negatively related to suicide ideation. Their measures of suicide ideation, however, were limited in that they were single-item questions, and they did not measure self-injurious behavior. Lewis’ (1971) distinction between the self-directed feeling of shame and the behavior-directed feeling of guilt gives support to the hypothesis that shame and guilt may have different effects on the presence and maintenance of NSSI. If “shame is considered the more painful emotion because one’s core self—not simply one’s behavior—is at stake” (Tangney et al., 2007, p. 349), then a person who is more shameprone, which is associated with defensiveness, separation, and distance, should be more likely to engage in NSSI than someone who is less shame-prone. A tendency toward feelings of guilt, which is associated with wanting to make amends and fixing what is wrong, may serve as a protective factor from engaging in NSSI. Given that shame-proneness and guilt-proneness have been implicated as risk and protective factors, respectively, for a variety of maladaptive behaviors, we evaluated whether these moral emotions play similar roles in NSSI. Shame-proneness and guilt-proneness are typically discussed as trait-like constructs (Tangney, Wagner, & Gramzow, 1992). While a person may have a situation-specific response in accordance with a shameful or guilty state, shame-proneness and guilt-proneness are more commonly

319 depicted as attributional styles, or the tendency to evaluate a range of situations similarly (Tangney, 1996). Thus, shame-prone persons are predisposed to blame their entire self, extrapolating their negative evaluation to themselves as a whole, for a behavioral transgression; a guilt-prone person is more likely to identify their specific behavior as problematic. Therefore, although the relation between NSSI and the internalizing emotions of anxiety and depression is well established (Nock et al., 2008), it is unknown if and how moral emotions contribute to this association. In the present study we sought to determine the association between internalizing tendencies (as measured by combined anxiety and depression scores) and moral emotions (shameproneness and guilt-proneness) in relation to the presence and frequency of NSSI. We expected that shame-proneness would be a risk factor, in that it was positively related to NSSI; conversely, we expected guiltproneness to negatively predict NSSI and serve as a protective factor. Furthermore, we examined whether these moral emotions moderate the relation between internalizing tendencies and NSSI. We expected that higher levels of shameproneness would exacerbate the relation between internalizing tendencies and frequency of NSSI, such that the association between internalizing tendencies and NSSI would be stronger when participants were more, as opposed to less, shame-prone. In contrast, we predicted that guilt-proneness would moderate the association between internalizing tendencies and frequency of NSSI such that having higher guilt-proneness, as opposed to less guilt-proneness, would generally protect against engaging in greater frequencies of NSSI, but this protective effect may dissipate as participants exhibited higher levels of internalizing tendencies. In other words, we expected the motivational and reparative function of guilt might be less effective when participants were overwhelmed by increased internalizing tendencies.

320

MORAL EMOTIONS, INTERNALIZING TENDENCIES, METHOD

Participants Three hundred and seventy-eight university undergraduate students were enrolled in a study on NSSI. Participants were recruited through SONA systems, an online research recruitment Web site, which gives university course credit in exchange for participation. Participants ranged in age from 18 to 51 years (M = 20.84, SD = 4.7), with females accounting for 71% of the sample. While the average age in this sample was appropriate for a college sample, 11.6% of participants were older than the “typical” college age of 23 years, a distribution which is reflective of the general student population of this university. Regarding year in school, 33% of the sample were freshmen, 27% were sophomores, 21% were juniors and 19% were seniors. The majority of participants identified themselves as Caucasian (51.2%), followed by Asian (22.9%), African American (7.5%), Hispanic (7%), or Other (11.3%). Measures Inventory of Statements about SelfInjury (ISAS). Participants completed the

AND

NSSI

ISAS, a self-report measure that assesses presence, frequency, and function of NSSI during their lifetime. Preliminary questions allow the individual to report the number of times they engaged in 12 different forms of NSSI deliberately and without suicidal intent (see Table 1; Klonsky & Olino, 2008). The ISAS has good stability over 1 year and good test–retest reliability (Glenn & Klonsky, 2011). Scores were summed to create a frequency of self-injurious acts. Five outliers were excluded from the analyses. Beck Anxiety Inventory (BAI). The BAI is a 21-item self-report questionnaire that assesses feelings of anxiety in the past week (Beck & Steer, 1990). Each item (e.g. “fear of losing control,” “terrified”) was scored on a 4-point Likert scale from 0 (not at all) to 3 (severely). Total scores ranged from 0 to 63, with higher scores indicating more severe anxious symptoms. The BAI has high internal consistency (a = .92), and a test–retest reliability over 1 week of .75 (Beck, Epstein, Brown, & Steer, 1988). The BAI was highly reliable in this sample (a = .92). Beck Depression Inventory (BDIII). The BDI-II is a 21-item self-report questionnaire that assesses feelings of depression in the past 2 weeks (Beck, Steer, & Brown, 1996). Each item (e.g. “sadness,”

TABLE 1

Descriptive Information about NSSI Type of Act

n

Mean Frequency

Standard Deviation

Range

Banging or hitting Pulling hair Pinching Cutting Interfering with wound healing Scratching Biting Burning Rubbing skin against rough surface Sticking self with needle Swallowing dangerous substances Carving

69 64 59 54 51 51 41 23 18 14 14 11

4.35 5.23 4.27 3.26 9.20 1.62 2.22 .31 .53 .27 .44 .12

25.08 31.52 28.42 27.37 55.30 7.58 17.19 1.81 3.70 1.83 3.96 .81

0–400 0–500 0–500 0–500 0–500 0–100 0–300 0–20 0–50 0–20 0–60 0–10

NSSI, nonsuicidal self-injury; n = number of participants who have reported engaging in this type of self-injurious act.

VANDERHEI

ET AL.

“social withdrawal”) was scored on a 4point Likert scale from 0 (not at all) to 3 (severely). Total scores ranged from 0 to 63, with higher scores indicating more severe depressive symptoms. The BDI-II has been reported as highly reliable across different population characteristics, such as age, sex, and ethnicity (Beck, Steer, & Brown, 2007). This scale has an average reliability coefficient of .86 and a test–retest reliability of .90 (Beck et al., 2007). The BDI-II was highly reliable in this sample (a = .91). Test of Self-Conscious Affect (TOSCA3). The TOSCA-3 measures individual propensities to experience shame and guilt in response to failures or transgressions (Tangney, Dearing, Wagner, & Gramzow, 2000). Sixteen different scenarios are followed by responses that represent shameproneness, guilt-proneness, externalization of blame, or detachment. One hypothetical scenario was: “You make a mistake at work and find out a co-worker is blamed for the error.” The shame response was “You would keep quiet and avoid the co-worker;” while the guilt response was “You would feel unhappy and eager to correct the situation.” Each response was rated on a Likert scale of 1 (not likely) to 5 (very likely), so an individual could score high on both, either, or neither moral emotion. Importantly, the words shame and guilt are never used in the hypothetical scenarios or responses. Separate total scores are calculated for shame-proneness and guilt-proneness, with each total score ranging from 16 to 80 and higher scores indicating greater endorsement of that construct. In other words, the shameproneness responses to each of the 16 scenarios would be summed to create a measure of how likely the participant would be to exhibit a shame-prone response. Tangney and Dearing (2002) found Cronbach’s alphas that ranged from .77 to .88 for shame-proneness, and .78 to .83 for guiltproneness. In our sample, shame-proneness (a = .77) and guilt-proneness both had acceptable reliability (a = .74). The test– retest reliability was .85 and .74 for shameproneness and guilt-proneness measures,

321 respectively, in a college sample (Tangney et al., 1992). While a person could be high on both guilt-proneness and shame-proneness, in this sample, shame-proneness and guilt-proneness scores were only moderately correlated (r = .31, p < .01). In accordance with the literature (Stuewig & McCloskey, 2005; Stuewig et al., 2010; Tangney et al., 2007), shame-proneness was residualized on guilt-proneness and vice versa to examine the unique influence of each respective construct. The resulting “guilt-free” shameproneness and “shame-free” guilt-proneness variables were used in subsequent analyses. Internalizing tendencies, shame-proneness, and guilt-proneness were centered to ease interpretation of the interactions. Procedure Prior to the commencement of the study, participants signed an informed consent form, which discussed the research purpose and procedures, risks, benefits, confidentiality, and alternatives to participation. In a small group setting, participants completed written individual self-report questionnaires, which lasted approximately an hour and a half. Upon completion of the study, participants were handed a debriefing form, which discussed the purpose of the study as examining personality and situational functions and factors of NSSI. Participants were provided with the contact information of the research team should they have follow-up questions or concerns. The university’s Human Subjects Review Board approved this study. Data Analysis Data were analyzed using SPSS for Windows, version 20 (Armonk, NY: IBM Corp., 2011). We modeled whether participants engaged in NSSI via logistic regression models. NSSI—coded 1 for yes and 0 for no—served as the dependent variable with internalizing tendencies and shameproneness or guilt-proneness as predictors, and age, school year, race and ethnicity, and sex as covariates. Race and ethnicity

322

MORAL EMOTIONS, INTERNALIZING TENDENCIES,

were dummy-coded, with “Other” as the reference group. Each logistic regression model contained the residualized score for either guilt-proneness or shame-proneness. Thus, one logistic regression used “shamefree” guilt-proneness and the other logistic regression used “guilt-free” shame-proneness as predictors of NSSI along with the specified covariates. First, we examined the effects of (1) internalizing tendencies, (2) shame-proneness, and (3) guilt-proneness on the presence of NSSI. If there were significant effects of shame-proneness or guiltproneness on the presence of NSSI, we then proceeded to test whether these effects remained after controlling for age, school year, race and ethnicity, sex, and internalizing tendencies. Finally, we ran models testing the interaction between each moral emotion and internalizing tendencies. To examine the frequency of NSSI, we ran negative binomial regression analyses, which accounted for the positively skewed frequency of the NSSI outcome variable (Hilbe, 2011). First, we examined the effects of (1) internalizing tendencies, (2) shame-proneness, and (3) guilt-proneness. If there were significant effects of the moral emotions on frequency of NSSI, we then tested how shame-proneness and guiltproneness predicted frequency of NSSI after controlling for age, school year, race and ethnicity, sex, and internalizing tendencies. We then looked at the interaction of (1) shame-proneness and internalizing tendencies and (2) guilt-proneness and internalizing tendencies when predicting frequency of NSSI. For all models that included internalizing tendencies, we also ran models that considered anxiety and depressive symptoms separately to further dissect the unique contribution of these two sets of symptoms.

RESULTS

Descriptive Statistics Consistent with previously reported findings, participants’ BAI and BDI-II

AND

NSSI

scores were highly correlated (r = .62, p < .01) and were therefore averaged and standardized to create a single internalizing tendencies score. Seventeen participants did not complete either the BAI or BDI-II and were excluded pairwise from subsequent analyses. Sixty-three of the 356 participants (17.7%) who completed the BDI-II were above the clinical cutoff of 17, as recommended by Beck et al. (1996). Fifty-seven of the 370 participants (15.4%) who completed the BAI were above the clinical cutoff of 16, as recommended by Beck and Steer (1993). With regard to shame-proneness and guilt-proneness, norms available for the TOSCA-3 indicate that students from a similar population (a large public university) reported average total shame scores of 46.25 (SD = 10.04) for females and 41.46 for males (SD = 9.65). In our analytic sample, females’ average total shame scores were 45.97 (SD = 9.75), while males’ were 43.06 (SD = 9.25). Norms available for average total guilt scores are 64.32 (SD = 7.20) for females and 60.28 (SD = 7.39) for males. In our sample, females’ averaged total scores were 64.97 (SD = 6.95), and males’ were 61.95 (SD = 9.16), indicating that this sample’s shame and guilt scores fell within the expected range for college students. Thirty-nine percent of the sample (n = 145) reported ever having engaged in NSSI. Forty-four percent of the males, and 37.9% of female participants, reported ever doing so. The most prevalent type of NSSI was “banging or hitting self” (n = 69). Ninety-five percent of those who engaged in NSSI reported doing so more than one time; 83.7% reported more than five NSSI acts. The mean frequency of NSSI acts was 31.87. See Table 1 for a complete list of NSSI acts and corresponding prevalence and frequencies. Of those who engaged in NSSI, the majority engaged in one type of behavior (i.e., cutting or carving; 24.3%). The mean reported age of first NSSI act was 11.38 years, with participants reporting an average of 8.67 years of NSSI. Sixty percent of those who engaged in NSSI

VANDERHEI

ET AL.

323

TABLE 2

Descriptive Statistics for Predictor and Outcome Variables Measure Presence of NSSI Frequency of NSSI Internalizing tendencies Shame-proneness Guilt-proneness

M

SD

Correlations

.39 31.87 19.99

.49 112.17 15.31

– .36** .32**

– .20**

45.12 64.20

9.67 7.72

.19** .07*

.16** .02

– .32** .11*

– .30**

–

*p < .05; **p < 0.01; N = 360 to 378; M = Mean; SD = standard deviation;

reported they were alone when they did so. Descriptive statistics and correlations between the predictor variables (internalizing tendencies, shame-proneness, and guiltproneness), presence of NSSI, and frequency of NSSI are presented in Table 2. Predicting Presence of NSSI At the bivariate level, internalizing tendencies were positively related to the presence of NSSI, v² (1) = 32.01, p < .01; odds ratio (OR) = 2.13, 95% confidence interval (95%CI) = 1.64–2.76. Similarly, shame-proneness was positively associated with the presence of NSSI at the bivariate level, v²(1) = 17.81, p < .01; OR = 1.65, 95% CI = 1.31–2.08. Age, v²(1) = .44, p = .51; OR = .98, 95%CI = .94–1.03; school year, v²(1) = 1.98, p = .16; OR = 1.15, 95%CI = .95–1.38; race and ethnicity, v²(1) = .84, p = .36; OR = .93, 95%CI = .80–1.08; and sex, v²(1) = 1.554, p = .21; OR = .75, 95%CI = .47–1.18, were all unrelated to whether someone engaged in NSSI. When including age, school year, race and ethnicity, sex, and internalizing tendencies, shame-proneness continued to be significantly and positively related to the presence of NSSI, v²(1) = 5.397, p = .02; OR = 1.37, 95%CI = 1.05–1.78. There was no significant interaction between shameproneness and internalizing tendencies. Conversely, guilt-proneness was negatively associated with the presence of NSSI at the bivariate level, v²(1) = 6.27, p = .01;

OR = .76; 95%CI = .62–.94. After including age, school year, race and ethnicity, sex, and internalizing tendencies, however, guilt-proneness was no longer significant, v²(1) = .192, p = .66; OR = .95; 95% CI = .75–1.20. There was no significant interaction between guilt-proneness and internalizing tendencies. Splitting tendencies into anxiety and depressive symptoms did not change the pattern of results for any of the models. Predicting Frequency of NSSI At the bivariate level, internalizing tendencies were positively related to frequency of NSSI, v²(1) = 64.28, p < .01; OR = 2.25; 95%CI = 1.85–2.75, as was shame-proneness, v²(1) = 4.81, p = .03; OR = 1.67; 95%CI = 1.06–2.65. Age, v²(1) = .39, p = .53; OR = 1.02; 95% CI = .95–1.10; school year, v²(1) = .80, p = .37; OR = 1.17; 95%CI = .83–1.65; and race and ethnicity, v²(1) = .37, p = .55; OR = .93; 95%CI = .74–1.18, were all unrelated to frequency of NSSI. Sex was related to frequency of NSSI, v²(1) = 4.37, p = .037; OR = .46; 95%CI = .22–.95, such that men tended to engage in higher frequencies of NSSI than women. Shameproneness remained predictive of frequency of NSSI, v²(1) = 6.03, p = .014; OR = 1.73; 95%CI = 1.12–2.69, after controlling for age, school year, race and ethnicity, sex, and internalizing tendencies. Given the exploratory nature of these analyses, we

324

MORAL EMOTIONS, INTERNALIZING TENDENCIES,

AND

NSSI

Figure 1. High and low levels of shame-proneness (1 standard deviation) across levels of internalizing tendencies on frequency of nonsuicidal self-injury. NSSI, nonsuicidal self-injury

was a significant interaction between guiltproneness and internalizing tendencies (Table 3). Figure 2 shows that high guiltproneness protects against higher frequencies of NSSI. Participants who were relatively lower on guilt-proneness had consistently higher frequencies of NSSI than those who were higher on guiltproneness, although the gap between the high and low guilt-proneness was attenuated at higher levels of internalizing tendencies. Thus, level of guilt-proneness matters less as participants exhibit more internalizing tendencies. These patterns remain when considering anxiety and depressive symptoms separately, as compared to the overall internalizing tendency score for both shame-proneness and guiltproneness models. Using post hoc simula-

graphically examined the relation between shame-proneness, internalizing tendencies, and frequency of NSSI (Figure 1). Internalizing tendencies were positively related to frequency of NSSI. Higher shame-proneness was associated with higher frequencies of NSSI than lower shame-proneness. Shame-proneness did not significantly moderate the relation between internalizing tendencies and frequency of NSSI, however (p = .13). Conversely, guilt-proneness was negatively associated with frequency of NSSI at the bivariate level, v²(1) = 9.22, p < .01; OR = .66; 95%CI = .50–.86, but did not remain significant after controlling for age, school year, race and ethnicity, sex, and internalizing tendencies, v²(1) = 2.21, p = .14; OR = .80; 95%CI = .60–1.07. There TABLE 3

Negative Binomial Regressions Predicting Frequency of NSSI from Internalizing Tendencies, GuiltProneness, and Their Interaction Predictor

B

Internalizing tendencies Guilt-proneness Internalizing tendencies X Guiltproneness

.73 .11 .31 .16 .21 .10

SE

Wald chi-square test 44.05** 3.50 4.50*

OR 2.06 .74 1.23

95%CI for OR 1.67 .53 1.02

2.56 1.02 1.50

N = 360 **p < .01 *p < .05. NSSI, nonsuicidal self-injury; OR = odds ratio; CI = confidence interval.

VANDERHEI

ET AL.

325

Figure 2. Interaction of internalizing tendencies and high and low levels of guilt-proneness (1 standard deviation) on frequency of nonsuicidal self-injury. NSSI, nonsuicidal self-injury.

tions in R, we found our power to detect interactions in the logistic regressions and the negative binomial regressions to be below .20.

DISCUSSION

Researchers and clinicians alike have been searching for meaningful and relevant risk factors that are associated with college students’ engagement in NSSI. The results of our study indicate that the moral emotions of shame-proneness and guilt-proneness may play a role in NSSI in a college sample. At the bivariate level, shame-proneness was positively related to both the presence of NSSI and the frequency of NSSI, while guilt-proneness was negatively related to both. Even when controlling for age, school year, race and ethnicity, sex, and internalizing tendencies, shame-proneness presented as a risk factor for both presence and frequency of NSSI. In moderation analyses, participants higher on guilt-proneness exhibited fewer acts of NSSI than those lower on guilt-proneness, but at higher levels of internalizing tendencies, this effect was attenuated. The interaction of guilt-proneness and internalizing tendencies illustrated that as participants reported higher levels of internalizing tendencies, the protective effect of high guilt-proneness

weakened with regard to frequency of NSSI. This study extends the extant shame and guilt literature, which asserts that shame-proneness is a risk factor and guiltproneness is a protective factor for several types of maladaptive behaviors such as criminal offending and substance use (Stuewig & Tangney, 2007; Stuewig et al., 2010; Tangney, Burggraf, & Wagner, 1995). While most of the literature on these moral emotions examined their effect on externalizing (Stuewig & Tangney, 2007) or internalizing (Tangney et al., 2007) problems, the present study extends the theoretical framework presented by Tangney and her colleagues to include NSSI, a decidedly mixed behavior. The results presented here suggest that high shame-proneness is a consistent risk factor across levels of internalizing tendencies, but the protective effect of high guilt-proneness is attenuated when a person also suffers from high levels of internalizing tendencies. Thus, the motivational and reparative function of high guilt-proneness, although still protective, is less influential for a person who has more anxious or depressive symptoms. Our findings are consistent with what we would expect from previous research, considering the different “action tendencies” (Lindsay-Hartz, 1984) elicited by feelings of shame-proneness or guilt-proneness.

326

MORAL EMOTIONS, INTERNALIZING TENDENCIES,

Shame-prone individuals negatively evaluate their entire self, instead of individual acts. It may be the case that at all levels of anxious and depressive symptoms (i.e., relatively low to relatively high), it is more likely that having high levels of shameproneness will lead to self-punishment (Linehan, 1993), as in the form of NSSI. In both psychiatric inpatient and community samples of adolescents, among the top selfreported reasons for engaging in NSSI are (a) to punish oneself and (b) to stop bad feelings (Lloyd-Richardson et al., 2007; Nock & Prinstein, 2004). Both of these automatically (as opposed to socially) reinforced functions of NSSI may help explain why higher shame-proneness is associated with higher frequencies of NSSI, as shameprone individuals are likely to see themselves, as a whole, of deserving of punishment. Future research would be prudent in examining how self-reported functions of NSSI map onto the interplay of shameproneness, guilt-proneness, and internalizing tendencies, with respect to NSSI, as this may shed light on why people at varying levels of shame- and guilt-proneness exhibit different patterns of NSSI. Conversely, guilt-prone individuals still feel bad, but they do not generalize the negativity to their entire being. Their feelings motivate compensatory action as a way of rectifying specific behaviors, without implicating their entire self. Guilt-prone individuals’ tendencies to engage in “other-oriented” corrective actions makes it less likely that those high in guilt-proneness would turn inwards and inflict harm upon themselves. However, a person with high levels of guilt-proneness (as opposed to low levels of guilt-proneness) who is also relatively more depressed and/ or anxious may not be as compelled to cope with his or her symptoms in much more productive and adaptive ways as compared to a person with less depressive or anxious symptoms. Although many of the study’s hypotheses were supported, we did not find evidence of an interaction between shameproneness and internalizing tendencies

AND

NSSI

when predicting frequency of NSSI. We hypothesized that level of shame-proneness would serve as a moderator such that at higher, as opposed to lower, levels of shame-proneness there would be a stronger association between internalizing tendencies and NSSI. One possible explanation is that our sample was both comprised (a) primarily of participants with subclinical anxiety and depressive symptoms (15.4% above clinical cutoff for BAI, and 17.7% above clinical cutoff for BDI-II), and (b) we had restricted range at the upper end of the BAI and BDI-II total scores. With possible total scores on both the BAI and BDI-II ranging from 0 to 63, the highest BDI score was 54 and the highest BAI-II score was 40. Given our low power to be able to detect interaction effects for binary logistic and negative binomial regressions, it is likely that we were unable to capture a sound picture of the relation between shame-proneness and internalizing tendencies at the very highest levels of internalizing tendencies. Future research is needed to examine the interaction of shame-proneness, internalizing tendencies, and frequency of NSSI with clinically depressed or anxious populations. It is also likely that shame-proneness, as a construct, can be further dissected. The TOSCA measures general shame-proneness; however, some have speculated that a domain-specific focus may be useful. For example, there is evidence that bodily shame, or self-conscious feelings about one’s own body, may have a unique relation with maladaptive behaviors, above and beyond general shame-proneness (Gilbert, 1989; Mollon, 1984; Sartre, 1956). Andrews (1997) found that bodily shame mediated the pathway from early childhood abuse to bulimia in adolescence and early adulthood. It would be fruitful to assess if and how this more specified type of shame would be related to NSSI. Although binging and purging-like behavior is not classified as NSSI, it can be viewed as self-injurious behavior, and examining whether those who endorse bodily shame are more likely to engage in NSSI than those who do not would be an

VANDERHEI

ET AL.

important avenue for future research. Similarly, there are probably issues of shame surrounding NSSI itself, which may play a role in further NSSI behavior. Exploring specific feelings of shame in these other domains may help paint the most complete picture of who is likely to start and maintain NSSI. Among the strengths of this study was the evaluation of a nonclinical sample of college students. As evidenced by the high prevalence rate of NSSI in this sample (39%), it is clear that community samples need to be continued to be evaluated for how typical variation in internalizing tendencies, shame-proneness, and guilt-proneness impact the likelihood of engaging in NSSI. Much research regarding NSSI has assessed clinical samples, and it is possible that the mechanisms and risk factors associated with the presence and frequency of NSSI for these samples are distinct from those in the general population (i.e., history of childhood abuse, presence of mental disorder; Klonsky & Moyer, 2008; Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006). Additionally, we assessed the moral emotions by evaluating “shame-free” guilt separately from “guilt-free” shame. This allowed us to examine the unique variance of each of these negative emotions to create a more sound and informative model of how separate moral emotions impact the relation of internalizing tendencies on NSSI. Even though this study was administered by laypersons in a community sample, we were able to account for internalizing tendencies (via BAI and BDI-II self-reports) as is normally presented in nonclinical settings. Additionally, we were able to detect a significant interaction between guilt-proneness and internalizing tendencies when predicting frequency of NSSI, in spite of having low power. Although this finding needs to be replicated in other samples and should therefore be interpreted with caution, it is all the more promising that this effect was significant in our analyses, given our power was below .20. This study is limited by a few notable concerns, as well. Primarily, there may have

327 been a self-selection effect of the students who volunteered to participate. The advertisement for this study stated that it was seeking to understand the risks and correlates of NSSI; thus, it is possible that we oversampled from the population of those who engage in NSSI by nature of the disclosure of the study’s interests, leading to possibly biased results. The prevalence rate in our sample, however, is not unlike rates found in other community samples of college students (Favazza, 1996; Gratz, 2006; Gratz et al., 2002). It is also possible that the method of NSSI assessment being a checklist may have inflated the prevalence of NSSI in our sample. Other studies that have used similar checklist-style surveys often report higher prevalence of NSSI than other methods, such as open-ended interviews (Heath, Schaub, Holly, & Nixon, 2008). The methods of NSSI included in our analyses may also have contributed to our sample’s somewhat high rate of NSSI. Some types of NSSI that were included in our analyses may not always be accurately depicted as NSSI and are subsequently excluded by other researchers, such as interfering with wound healing, sticking self with needles, or rubbing skin against rough surface. This concern is tempered, however, by the reality that very few of the participants who engaged in these types of behaviors did so to the exclusion of other types of NSSI (five participants engaged exclusively in interfering with wound healing; one participant engaged exclusively in sticking self with needles; one participant engaged exclusively in rubbing skin against rough surface). Therefore, we are confident that we did not include many participants in our NSSI sample that did not truly represent NSSI behaviors. Furthermore, we do not know whether our participants had ever sought or been in treatment for these behaviors, and thus, we cannot say that our sample is definitely not comprised in part by a clinical subsample. Finally, the crosssectional nature of our design inherently limits our ability to draw certain causal connections about the risk factors we are

328

MORAL EMOTIONS, INTERNALIZING TENDENCIES,

examining. However, the trait-like nature of shame- and guilt-proneness attenuates this concern, as there is relative stability in these constructs (Tangney, 1996). The reader should be cautioned, however, when interpreting the residualized “shame-free” guiltproneness and “guilt-free” shame-proneness effects on NSSI, as shame-proneness and guilt-proneness cannot be residualized out from each other in reality. The strong correlation between these two constructs implies that some people may engage in high levels of both shame- and guilt-proneness. The analyses presented here examine guilt-proneness and shame-proneness with the shared variance removed, meaning that some shame-proneness for one person or some guilt-proneness for another person was not directly assessed. Thus, it is important to keep in mind that people may endorse varying levels of both shame-proneness and guilt-proneness “in real life.” The fundamental pattern represented by these results is that moral emotions may play a role in NSSI. Anxiety and depression are well-known risk factors for NSSI; shame-proneness continued to show a relation above and beyond internalizing tendencies; and guilt-proneness interacted with internalizing tendencies, suggesting these moral emotions should be considered when attempting to identify those teens and young adults who are at heightened risk for engaging in NSSI. It is critical that researchers and clinicians are able to

AND

NSSI

identify key risk factors, such as high shame-proneness and low guilt-proneness, as for many individuals, the consequence of just one NSSI episode can be very serious. Yet, this is not the full story. Shameand guilt-proneness also may play a role in buffering or exacerbating the effects of internalizing tendencies on NSSI. There are likely myriad pathways to initiating and sustaining NSSI; moving beyond main effects and investigating how psychological and emotional risk factors work together will enlighten this field of research. Furthermore, understanding these risk factors and processes may help front-line professionals treat those who are engaging in maladaptive and dangerous behavior. The risk associated with high shame-proneness and low guilt-proneness, as illustrated by these results, support intervention and treatment efforts, which aim to not only reduce shame-prone responses but also enhance more guilt-prone responses. Cognitive therapies, for example, which are action-oriented and focus on the problembehaviors, may help to reduce the tendency for a person to negatively evaluate their entire self. Helping to reorganize the thought process of someone who engages in NSSI to constructive, reparative actions in response to their NSSI, instead of extrapolating blame to their entire self, would reduce shame-proneness and improve the protective effect of guiltproneness.

REFERENCES ANDOVER, M. S., & GIBB, B. E. (2010). Non-suicidal self-injury, attempted suicide, and suicidal intent among psychiatric inpatients. Psychiatry Research, 178, 101–105. ANDREWS, B. (1997). Bodily shame in relation to abuse in childhood and bulimia: A preliminary investigation. British Journal of Clinical Psychology, 36, 41–49. ASARNOW, J. R., PORTA, G., SPIRITO, A., EMSLIE, G., CLARKE, G., WAGNER, K. D., ET AL. (2011). Suicide attempts and nonsuicidal selfinjury in the treatment of resistant depression in adolescents: Findings from the TORDIA study.

Journal of the American Academy of Child and Adolescent Psychiatry, 50, 772–781. BECK, A. T., EPSTEIN, N., BROWN, G., & STEER, R. A. (1988). An inventory for measuring clinical anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology, 56, 603–614. BECK, A. T., & STEER, R. A. (1993). Beck Anxiety Inventory manual. San Antonio, TX: The Psychological Corporation. BECK, A. T., STEER, R. A., & BROWN, G. K. (1996). Manual for the Beck Depression Inventory. (BDI-II; 2nd ed.). San Antonio, TX: The Psychological Corporation.

VANDERHEI

ET AL.

BECK, A. T., STEER, R. A., & BROWN, G. K. (2007). Beck Depression Inventory (2nd ed.). San Antonio, TX: The Psychological Corporation. BRIERE, J., & GIL, E. (1998). Self-mutilation in clinical and general population samples: Prevalence, correlates and functions. American Journal of Orthopsychiatry, 68, 609–620. Centers for Disease Control and Prevention. (2008). Web-based injury statistics query and reporting system (WISQARS) nonfatal injury reports. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. CHARTRAND, H., SAREEN, J., TOEWS, M., & BOLTON, J. M. (2012). Suicide attempts versus nonsuicidal self-injury among individuals with anxiety disorders in a nationally representative sample. Depression and Anxiety, 29, 172–179. DEARING, R. L., STUEWIG, J., & TANGNEY, J. P. (2005). On the importance of distinguishing shame from guilt: Relations to problematic alcohol and drug use. Addictive Behaviors, 30, 1392– 1404. EISENBERG, N. (2000). Emotion, regulation, and moral development. Annual Review of Psychology, 51, 665–697. FAVAZZA, A. R. (1996). Bodies under siege: Self-mutilation in culture and psychiatry (2nd ed.). Baltimore: Johns Hopkins University Press. FERGUS, T. A., VALENTINER, D. P., MCGRATH, P. B., & JENCIUS, S. (2010). Shame- and guilt-proneness: Relationships with anxiety disorder symptoms in a clinical sample. Journal of Anxiety Disorders, 24, 811–815. GILBERT, P. (1989). Human nature and suffering. London: Erlbaum. GLENN, C. R., & KLONSKY, E. D. (2011). One-year test-retest reliability of the inventory of statements about self-injury (ISAS). Assessment, 18, 375–378. GOSS, K., & ALLAN, S. (2009). Shame, pride and eating disorders. Clinical Psychology & Psychotherapy, 16, 303–316. GRATZ, K. L. (2006). Risk factors for deliberate self-harm among female college students: The role and interaction of childhood maltreatment, emotional inexpressivity, and affect intensity/reactivity. American Journal of Orthopsychiatry, 76, 238–250. GRATZ, K. L., CONRAD, S. D., & ROEMER, L. (2002). Risk factors for deliberate self-harm among college students. American Journal of Orthopsychiatry, 72, 128–140. HASTINGS, M. E., NORTHMAN, L. M., & TANGNEY, J. P. (2000). Shame, guilt, and suicide. In T. E. Joiner & M. D. Rudd (Eds.), Suicide science: Expanding the boundaries (pp. 67–79). Norwell, MS: Kluwer Academic.

329 HEATH, N. L., SCHAUB, K. M., HOLLY, S., & NIXON, M. K. (2008). Self-injury today: Review of population and clinical studies in adolescents. In M. K. Nixon & N. L. Heath (Eds.), Self-injury in youth: The essential guide to assessment and intervention (pp. 9–28). New York: Routledge. HILBE, J. M. (2011). Negative binomial regression (2nd ed.). New York: Cambridge University Press. HOFF, E. R., & MUEHLENKAMP, J. J. (2009). Nonsuicidal self-injury in college students: The role of perfectionism and rumination. Suicide and Life-Threatening Behavior, 39, 576– 587. JACOBSON, C. M., & GOULD, M. (2007). The epidemiology and phenomenology of nonsuicidal self-injurious behavior among adolescents: A critical review of the literature. Archives of Suicide Research, 11, 129–147. JOINER, T. E. (2005). Why people die by suicide. Cambridge: Harvard University Press. KLONSKY, E. D. (2011). Non-suicidal selfinjury in United States adults: Prevalence, sociodemographics, topography and functions. Psychological Medicine, 41, 1981–1986. KLONSKY, E. D., & MOYER, A. (2008). Childhood sexual abuse and non-suicidal selfinjury: Meta analysis. The British Journal of Psychiatry, 192, 166–170. KLONSKY, E. D., & OLINO, T. M. (2008). Identifying clinically distinct subgroups of selfinjurers among young adults: A latent class analysis. Journal of Consulting and Clinical Psychology, 71, 22–27. LEWIS, H. B. (1971). Shame and guilt in neurosis. New York: International Universities Press. LINDSAY-HARTZ, J. (1984). Contrasting experiences of shame and guilt. American Behavioral Scientist, 27, 689–704. LINEHAN, M. M. (1993). Cognitive-behavioral treatment for borderline personality disorder. New York: Guilford. LLOYD-RICHARDSON, E. E., PERRINE, N., DIERKER, L., & KELLEY, M. L. (2007). Characteristic and functions on non-suicidal self-injury in a community sample of adolescents. Psychological Medicine, 37, 1183–1192. MOLLON, P. (1984). Shame in relation to narcissistic disturbance. British Journal of Medical Psychology, 57, 207–214. MUEHLENKAMP, J. J., & GUTIERREZ, P. M. (2007). Risk for suicide attempts among adolescents who engage in non-suicidal self-injury. Archives of Suicide Research, 11, 69–82. NOCK, M. K. (2010). Self-injury. Annual Review of Clinical Psychology, 6, 339–363. NOCK, M. K., & FAVAZZA, A. R. (2009). Nonsuicidal self-injury: Definition and classifica-

330

MORAL EMOTIONS, INTERNALIZING TENDENCIES,

tion. In M. K. Nock (Ed.), Understanding nonsuicidal self-injury: Origins, assessment, and treatment (pp. 9–18). Washington, DC: American Psychological Association. NOCK, M. K., JOINER, T. E., GORDON, K. H., LLOYD-RICHARDSON, E., & PRINSTEIN, M. J. (2006). Non-suicidal self-injury among adolescents: Diagnostic correlates and relation to suicide attempts. Psychiatry Research, 144, 65–72. NOCK, M. K., & PRINSTEIN, M. J. (2004). A functional approach to the assessment of selfmutilative behavior. Journal of Consulting and Clinical Psychology, 72, 885–890. NOCK, M. K., WEDIG, M. M., HOLMBERG, E. B., & HOOLEY, J. M. (2008). The Emotion Reactivity Scale: Development, evaluation, and relation to self-injurious thought and behaviors. Behavior Therapy, 39, 107–116. ROSS, S., & HEATH, N. (2002). A study of the frequency of self-mutilation in a community sample of adolescents. Journal of Youth and Adolescence, 31, 67–77. SARTRE, J. P. (1956). Being and nothingness. New York: Philosophical Library. STUEWIG, J., & MCCLOSKEY, L. A. (2005). The relation of child maltreatment of shame and guilt among adolescents: Psychological routes to depression and delinquency. Child Maltreatment, 10, 324–336. STUEWIG, J., & TANGNEY, J. P. (2007). Shame and guilt in antisocial and risky behaviors. In J. L. Tracy, R. W. Robins, & J. P. Tangney (Eds.), The self-conscious emotions: Theory and research (pp. 371–388). New York: Guilford. STUEWIG, J., TANGNEY, J. P., HEIGEL, C., HARTY, L., & MCCLOSKEY, L. (2010). Shaming, blaming, and maiming: Functional links among the moral emotions, externalization of blame, and aggression. Journal of Research in Personality, 44, 91–102. TANGNEY, J. P. (1991). Moral affect: The good, the bad, and the ugly. Journal of Personality and Social Psychology, 61, 598–607.

AND

NSSI

TANGNEY, J. P. (1996). Conceptual and methodological issues in the assessment of shame and guilt. Behaviour Research and Therapy, 34, 741–754. TANGNEY, J. P., BURGGRAF, S. A., & WAGNER, P. E. (1995). In J. P. Tangney & K. W. Fischer (Eds.), Self-conscious emotions: The psychology of shame, guilt, embarrassment, and pride (pp. 343– 367). New York: Guilford. TANGNEY, J. P., & DEARING, R. (2002). Shame and guilt. New York: Guilford. TANGNEY, J. P., DEARING, R. L., WAGNER, P. E., & GRAMZOW, R. (2000). The Test of SelfConscious Affect-3 (TOSCA-3). Fairfax, VA: George Mason University. TANGNEY, J. P., STUEWIG, J., & MASHEK, D. (2007). Moral emotions and moral behavior. Annual Review of Psychology, 58, 345–372. TANGNEY, J. P., WAGNER, P., FLETCHER, C., & GRAMZOW, R. (1992). Shamed into anger? The relation of shame and guilt to anger and self-reported aggression. Journal of Personality and Social Psychology, 62, 669–675. TANGNEY, J. P., WAGNER, P., & GRAMZOW, R. (1992). Proneness to shame, proneness to guilt, and psychopathology. Journal of Abnormal Psychology, 101, 469–478. TANGNEY, J. P., WAGNER, P. E., HILLBARLOW, D., MARSCHALL, D. E., & GRAMZOW, R. (1996). Relation of shame and guilt to constructive versus destructive responses to anger across the lifespan. Journal of Personality and Social Psychology, 71, 797–809. WRIGHT, K., GUDJONSSON, G. H., & YOUNG, S. (2008). An investigation of the relationship between anger and offence-related shame and guilt. Psychology, Crime & Law, 14, 415–423. Manuscript Received: March 26, 2013 Revision Accepted: August 30, 2013