Shame and Depressive Symptoms: Self-Compassion and Contingent Self-Worth As Mediators?

Journal of Clinical Psychology in Medical Settings https://doi.org/10.1007/s10880-018-9548-9

Shame and Depressive Symptoms: Self-compassion and Contingent Self-worth as Mediators?

Huaiyu Zhang1 · Erika R. Carr2 · Amanda G. Garcia-Williams3 · Asher E. Siegelman4 · Danielle Berke5 · Larisa V. Niles-Carnes3 · Bobbi Patterson3 · Natalie N. Watson-Singleton6 · Nadine J. Kaslow3

Abstract Research has identified the experience of shame as a relevant predictor of depressive symptoms. Building upon resilience theory, this is the first study to investigate if self-compassion and/or contingent self-worth (i.e., family support and God’s love) mediate the link between shame and depressive symptoms. Participants were 109 African Americans, within the age range of 18 and 64, who sought service following a suicide attempt from a public hospital that serves mostly low-income patients. Findings suggest that shame was related to depressive symptoms through self-compassion but not through contingent self-worth, underscoring the significant role that self-compassion plays in ameliorating the aggravating effect of shame on depressive symptoms. Results highlight the value of incorporating self-compassion training into interventions for suicidal African Americans in an effort to reduce the impact of shame on their depressive symptoms and ultimately their suicidal behavior and as a result enhance their capacity for resilience.

Keywords African Americans · Self-compassion · Contingent self-worth · Shame · Depressive symptoms

Introduction to adapt successfully following adversity (Roisman, 2005). Self-compassion and contingent self-worth, two personal Shame has been implicated in the development of a vari- resources, may offer alternative models for responding to ety of psychological problems including depressive symp- shame that promote resilience and in turn reduce people’s toms, depression, and suicidal behavior (Kim, Thibodeau, vulnerability to depressive symptoms (Neff, 2003b; Sta- & Jorgensen, 2011; Pinto-Gouveia & Matos, 2011). Resil- pleton, Crighton, Carter, & Pidgeon, 2017; Trompetter, de ience theory offers a rubric for conceptualizing the ways Kleine, & Bohhlmeijer, 2017). in which people rebound from shame through a process Shame refers to an experience of being negatively evalu- of self-reconstruction so that the potentially debilitating ated by others and/or oneself, and it results in feeling defi- impact of this painful emotion on psychological adjust- cient, small, powerless, or worthless (Kim et al., 2011). Peo- ment can be ameliorated (Van Vliet, 2008). Resilience, a ple who endorse high levels of depressive symptoms also dynamic and multifaceted process, refers to the capacity self-report high levels of shame (Pinto-Gouveia & Matos, for drawing on personal and contextual resources in order 2011; Robinaugh & McNally, 2010). Longitudinal studies suggest that shame predicts depressive symptoms (Andrews, * Huaiyu Zhang Qian, & Valentine, 2002). There is a stronger link between [email protected] shame and depressive symptoms, than between other constructs (e.g., guilt) and depressive symptoms, highlighting 1 University of California San Francisco, 2727 Mariposa St, the value of understanding the role shame plays in the onset Suite 100, San Francisco, CA 94110, USA and maintenance of depressive symptoms (Kim et al., 2011). 2 Yale University, New Haven, CT, USA To date, no studies have examined the shame–depressive 3 Emory University School of Medicine, Atlanta, GA, USA symptoms in low-income African Americans. 4 Catholic University of America, Washington, DC, USA It is valuable to identify resilience factors that buffer the 5 University of Georgia, Athens, GA, USA shame–depressive symptom link. Self-compassion, which originates from Buddhist philosophy, is one such potential 6 Spelman College, Atlanta, GA, USA

Vol.:(0123456789)1 3 Journal of Clinical Psychology in Medical Settings resilience mechanism (Neff, 2003a; Terry, Leary, & Mehta, the self-compassion–depressive symptom link is mediated 2013). Self-compassion means being connected to and by symptom-focused rumination and cognitive-behavioral touched by one’s own experience of suffering as part of the avoidance (Krieger, Altensetin, Baettig, Doerig, & Hol- human experience and embracing a desire or motivation ltforth, 2013). Self-compassion may play a buffering role to personally heal (Neff, 2003a). It includes three pairs of via the amelioration of self-criticism, social isolation, and mutually reinforcing qualities: (1) common humanity (vs. over-identification with negative thoughts and feelings (Neff, separation/isolation)—seeing one’s experiences as common 2003a). Consistent with this, depressive symptoms are nega- to that of many people; (2) self-kindness (vs. self-judgment/ tively associated with positive qualities of self-compassion self-criticism)—being kind and understanding of oneself; (common humanity, self-kindness, mindfulness) and posi- and (3) mindfulness (vs. over-identification)—having a bal- tively associated with negative qualities of self-compassion anced awareness, clarity, and acceptance of thoughts and (separation/isolation, self-judgment/self-criticism, over- feelings. Self-compassion is negatively associated with identification) (Barnard & Curry, 2011). Data from inter- depressive symptoms, anxiety, and eating problems; self- vention studies with individuals with depression suggest that criticism, fear of failure, and a tendency to interpret failure increasing self-compassion through self-compassion training as an indication of competence; thought suppression; and decreases depressive symptoms (Kuyen et al., 2010; Shahar neurotic perfectionism (Barnard & Curry, 2011; Neff, 2011). et al., 2012). It is positively associated with happiness, optimism, a ten- Another resilience factor that may buffer the effects of dency to interpret failure as a difficulty performing rather shame on depressive symptoms is contingent self-worth, than personal incompetence, personal initiative and curios- which refers to a sense of self-value dependent on other ity, wisdom, life satisfaction, emotional intelligence, and (mostly external) factors. Individuals with high contingent social connectedness (Barnard & Curry 2011; Neff, 2011). self-worth believe they obtain value as a person by behav- In keeping with resilience theory, self-compassion may ing in a certain way or attaining particular goals. Domains serve as an adaptive, self-supportive strategy in which indi- salient to contingent self-worth include physical appear- viduals hold warm-hearted, caring, empathic, and nonjudg- ance, academic competence, outdoing others in competi- mental views of themselves during times of failure; thus, it tion, virtue, others’ approval, family support, and God’s love may buffer against the development of depressive symptoms (Crocker and Knight 2005). Mixed findings have emerged as (Neff, 2003b; Trompetter et al., 2017). to whether contingent self-worth is a liability or an asset. It Given that shame is associated with increased psycho- has been posited that contingent self-worth could be at risk pathology among African Americans (O’Connor, Berry, when failure is encountered; failure to achieve in particular & Weiss, 1999) and self-compassion is associated with domains of contingent self-worth may lead to feelings of decreased psychopathology and a greater sense of well- shame, sadness/depressive symptoms, worthlessness, and being in this population (Neff, Kirkpatrick, & Rude, 2007), anger (Crocker & Parker, 2004; Kim et al., 2011). However, an inverse connection between shame and self-compassion data also indicate that contingent self-worth leads to posi- has been posited (Neff, 2003a). Negative self-evaluation tive affect, high self-esteem, and a sense of pride (Crocker and social isolation are key aspects of shame, and they are & Knight 2005; Crocker & Parker 2004). Given these mixed opposite to self-kindness and connection with others empha- findings, more research is needed, especially with regard to sized in self-compassion (Gilbert & Procter, 2006). The the possible ways in which contingent self-worth can serve shame–self-compassion link is supported in efficacy stud- as a resilience mechanism. ies of compassion-based interventions (Barnard & Curry, Although research suggests that both self-compassion and 2011; Gilbert & Procter, 2006; Kelly, Carter, & Borairi, contingent self-worth may be potential personal resilience 2014). When self-judgment/criticism, isolation, and over- resources that influence the shame–depressive symptom identification are reduced, self-compassion is higher, shame link, self-compassion may be more beneficial overall than is lower, and treatment outcomes are enhanced. Additionally, contingent self-worth. One’s perceived self-compassion is it may be helpful to conceptualize the idea that a relationship characterized by a sense of acceptance, self-kindness in the between self-compassion and shame constructs may occur face of failure, nonjudgmental acceptance of the present on a type of continuum, rather than in a binary relationship. moment, and appreciation of human imperfection (Neff & The utility of modifying shame via self-compassion is Vonk, 2009). Therefore, the construct of self-compassion supported by evidence that self-compassion protects against may be an effective way of developing a value for the self depressive symptoms. In a recent meta-analysis, a large and personal self-conceptualization (Neff, 2003a). In con- effect size was found for the association between self-com- trast, although the concept of contingent self-worth con- passion and depressive symptoms (r = − .52); depressed tributes to a sense of pride and personal accomplishment, individuals had lower levels of self-compassion than non- such perception may only provide temporary reassurance depressed persons (MacBeth & Gumley, 2013). Further, of one’s worth, making this type of self-value unstable and

1 3 Journal of Clinical Psychology in Medical Settings vulnerable (Ryan & Brown, 2003). Moreover, reductions diverse ethnicities, there have been differences also shown in self-esteem that occur as a result of failure in domains for Asians in comparison to other ethnicities in how they of contingent self-worth may be greater than the benefits experience contingent self-worth based on academics (Park, derived from successes in the same domains (Crocker & Crocker, & Kiefer, 2007). This may indicate the need to fur- Knight, 2005; Crocker & Parker, 2004). Thus, one’s high ther examine diverse cultural groups and their experience of sense of contingent self-worth can be advantageous when contingent self-worth, as different values may be held among personal standards are achieved, but limited in its benefits diverse groups of people. when those standards are not met (Neff & Vonk, 2009). To advance our understanding of the shame–depressive Relatedly, perceived self-compassion may have more long- symptoms link in low-income African Americans, this study lasting effects than perceived contingent self-worth. utilizes a resilience framework to guide the examination The limited research comparing the construct of self- of the associations among shame, self-compassion, con- compassion and contingent self-worth shows that self- tingent self-worth, and depressive symptoms in an urban, compassion predicts more constant feelings of self-worth low-income group of African Americans presenting to a than global self-esteem, a construct similar to contingent hospital after a suicide attempt. In accord with resilience self-worth (Neff & Vonk, 2009). It also indicates that one’s theory, the following hypotheses are proposed: (1) the expe- sense of self-compassion is less contingent on particular out- rience of shame will be positively associated with depressive comes than self-esteem, supporting the prediction that self- symptoms; (2) the experience of shame will be negatively compassion may be more adaptive than contingency-based associated with both self-compassion and contingent self- self-evaluations. The view that self-compassion serves as a worth; (3) both self-compassion and contingent self-worth more effective resilience mechanism than contingent self- will be negatively associated with depressive symptoms; worth has received some empirical attention, but warrants and (4) self-compassion and self-worth contingent on fam- additional research, especially among diverse populations in ily support or God’s love will mediate the shame–depressive terms of race/ethnicity and social class (Neff, 2003a; Neff symptom link, but self-compassion will demonstrate a larger & Vonk, 2009). effect than contingent self-worth (Fig. 1). Clarifying these Few studies have examined self-compassion and con- associations can shed light on the targets for interventions tingent self-worth in the well-being of African Ameri- designed to reduce the impact of shame on depressive symp- cans. Studies with diverse ethnic groups indicate that self- toms among high-risk, low-income African Americans. In compassion is associated with lower levels of depressive addition, findings from this study will advance our under- symptoms specifically and poor mental health more gener- standing of individuals served in urban public healthcare ally (Ghorbani, Watson, Chen, & Norballa, 2012; Wong & systems and can contribute to best practices in the delivery Mak, 2013; Yarnell & Neff, 2013). Additional investigation of evidence- and resilience-based psychological practices is needed to elucidate the role of self-compassion in the rela- in these systems. The research also can serve as a model for tion between shame and depressive symptoms in general the conduct of clinically relevant psychological research in (Pace et al., 2013; Reddy et al., 2013; Woods-Giscombé & such public sector medical settings. Black, 2010), as well as with specific populations such as low-income African Americans. Despite limited empirical attention to contingent self-worth, one study indicates that Method African American college students, compared to other ethnic groups, may be more prone to have contingent self-worth Participants based on God’s love rather than other domains of contingent self-worth (Zeigler-Hill, 2007). This could be due to the This study was conducted at an urban public hospital that salience of faith and spirituality within African American serves socioeconomically disadvantaged individuals, most of culture and the extensive empirical support which identi- whom are racial and ethnic minorities. There were a total of fies spirituality as most valued among African Americans in 109 participants who self-identified as African American, 45 the United States, in comparison to other ethnicities (Boyd- males and 64 females. Recruitment and screening were con- Franklin, 2003; Boyd-Franklin & Lockwood, 2009; Cheng, ducted in the hospital’s inpatient unit and outpatient clinics as Kwan, & Sevig, 2013). Family support is also a relevant well as the emergency room. Inclusion criteria included having cultural value for African Americans (Boyd-Franklin, 2003; a suicide attempt in the past year, being between the ages of Matlin, Molock, & Tebes, 2011). Thus, this study exam- 18–64, having adequate cognitive function measured with the ined two components of contingent self-worth—God’s love Mini-Mental State Exam (Folstein, Folstein, McHugh, & Fan- and family support—that are consistent with core African jiang, 2001), displaying the absence of or a low number of psy- American cultural values. Interestingly, though the research chotic symptoms as measured by a Psychotic Screen (Kaslow as suggested above needs to be further elucidated among et al., 2010), and reporting the absence of any life-threatening

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a Self-Compassion(M1) b1 1 Covariates: Age Gender Relationship c' Experience of Shame(X) Depressive Symptoms (Y) status Homelessness a b Unemployment 2 2 a 3 CSW: Family Support(M ) b Monthly Income 2 3

CSW: God’s Love (M3)

Fig. 1 Path diagram showing multiple mediator model. CSW: Family Support stands for self-worth contingent upon family support and CSW: God’s Love stands for self-worth contingent upon God’s love medical condition. The Psychotic Screen is an 8-item scale Shame that asks about symptoms in the past week. The items are rated on a 5-point scale, ranging from not at all (0) to extremely The ESS (Andrews et al., 2002) consists of 25 self- (4). Individuals are excluded if their total scores are > 24. It report items, and the total score of the scale is used to is important to note the multitude of intersecting psychoso- assess one’s experience of shame. Example items include cial stressors this population experienced due to racism (e.g., “shame of personal habits,” “shame about doing some- discrimination) and intense poverty (e.g., insecure housing, thing wrong,” and “feeling ashamed of (your) body or lack of insurance, limited educational attainment). Given any part of it.” Scoring is based on a 4-point Likert scale the unique challenges faced by this sample, it is important from 1 (not at all) to 4 (very much), and total scores range to consider how these challenges may shape how we under- between 25 and 100. Research has shown that the scale stand the implications of the study ﬁndings. The participants’ is high on internal consistency and test–retest reliability response rate was 74%. (Andrews et al., 2002). The ESS demonstrated high internal consistency (α = 0.96) in this study. Procedure

The current study was part of a longitudinal investigation Depressive Symptoms that examined the eﬀect of a compassion-based intervention on African American men and women following a The BDI-II (Beck, Steer, Ball, & Ranieri, 1996) consists of suicide attempt. Only data gathered at the pre-intervention 21 items that assess the severity of depressive symptoms. assessment were used for this study. The assessment lasted Some examples of items are “sadness,” “guilt,” “social approximately one hour, and each participant was com- withdrawal,” and “loss of appetite.” Scoring is based on a pensated $20. During the assessment, nine questionnaires 4-point Likert scale that ranges from 0 to 3 for a possible were administered, and ﬁve were used for the current study, total score of 63. Severity of depressive symptoms is cat- including the Demographic Questionnaire, Experience of egorized by respondent’s total score, which ranges from Shame Scale (ESS), Beck Depression Inventory-II (BDI-II), “minimal” (0–13), “mild” (14–19), “moderate” (20–28), Self-Compassion Scale (SCS), and Contingencies of Self- to “severe” (29–63). The BDI-II has consistently demon- Worth Scale (CSWS). strated adequate reliability and validity (Beck et al., 1996; Joe & Neidermeier, 2008), with internal consistency, and Measures test–retest reliability, as well as construct, convergent, and discriminant validity established from investigations Demographics across various clinical populations, including African Americans (Sashidharan, Pawlow, & Pettibone, 2012; Basic demographic information of the participants, such as Uslu, Kapci, Oncu, Ugurlu, & Turkcaper, 2008). The age, gender, relationship status, and monthly income, was BDI-II also demonstrated excellent internal consistency collected using the Demographic Questionnaire. (α = 0.91) in this study.

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Self-compassion alphas for family support and god’s love were 0.50 and 0.87, respectively. The SCS (Neff, 2003a) consists of 26 items that assess individuals’ level of self-compassion along three key dimensions: common humanity versus separation/isola- Statistical Analyses tion, self-kindness versus self-judgment/self-criticism, and mindfulness versus over-identification. Since measuring SPSS 20.0 was used to run statistical analyses. First, data self-compassion as a unified construct is well validated and were cleaned and assessed for missing values. There were common practice in other studies, only the total SCS score no missing data in the current study as all participants com- is used for the analyses (Barnard & Curry, 2011; Kelly et al., pleted the survey questionnaires. The first, second, and 2014; Kuyen et al., 2010; Neff, 2003a). Example items are: third hypotheses were examined using partial correlations. “I try to be understanding and patient toward aspects of my For the fourth hypothesis, path analyses for the mediation personality I don’t like,” “I’m disapproving and judgmental model with multiple mediators were conducted to exam- about my own flaws and inadequacies,” and “When some- ine the indirect effect between shame, the predictor, and thing painful happens I try to take a balanced view of the depressive symptoms, the outcome (Preacher & Hayes, situation.” Scoring of the SCS is based on a 5-point Likert 2008). Bootstrapping has been recommended when testing scale that ranges from 1 (almost never) to 5 (almost always). indirect effects of mediators because it examines statistical Total scores range from 26 to 130. Psychometric properties significances but does not assume normality in the sampling have been evaluated cross-culturally and have established distribution (Preacher & Hayes, 2008). In this study, the that the SCS total scale has good internal consistency and SPSS Macro function was used to generate bootstrap esti- test–retest reliability, as well as construct, content, and mates based on 10,000 resamples for the mediation model convergent validity (Deniz, Kesici, & Sumer, 2008; Neff, (Hayes, 2013). Percent mediation effect sizes (i.e., media- 2003a). Analyses of the SCS with this sample shows that the tion ratios) were calculated for indirect effects (Preacher & measure has acceptable internal consistency (α = 0.74). No Kelley, 2011). other psychometric data are available for this measure with African Americans. Results Contingent Self-Worth Table 1 presents demographic information and Table 2 The CSWS (Crocker, Luhtanen, Cooper, & Bouvrette, 2003) provides descriptive statistics of study measures and par- consists of 35 items that assess seven different contingen- tial correlations among measures. The following covariates cies upon which people base their self-worth. Two of these were selected based on the literature (Baker & McNulty, contingencies, Family Support and God’s Love, were used 2011; Neff & Beretvas, 2013): age, monthly income, gen- in this study due to the relevance to this population. Two der, homelessness, unemployment, and relationship status. example items from Family Support are: “It is important to Correlations between age, monthly income, and key study my self-respect that I have a family that cares about me,” and variables revealed that age was positively associated with “When my family members are proud of me, my sense of God’s love, such that as age increased, self-reported levels of self-worth increases.” Two examples from God’s Love are: God’s love also increased (Table 2). Also, monthly income “My self-esteem goes up when I feel that God loves me,” was negatively associated with depressive symptoms, such and “My self-esteem would suffer if I didn’t have God’s that reported increases in income related to reductions in love.” Scoring of the CSWS is based on a 7-point Likert depressive symptoms. Given that gender, homelessness, scale that ranges from 1 (strongly disagree) to 7 (strongly unemployment, and relationship status represented dichoto- agree) (Park & Crocker, 2008). Each of these subscales com- mous variables, independent sample t tests were performed prised 5 items with total scores ranging from 5 to 35. The to assess if these socioeconomic factors were associated with CSWS has been shown to have high internal consistency, differences in key variables. There were no gender differ- good test–retest reliability, construct, and discriminant valid- ences across study variables (all p’s > .05). Despite these ity as well as convergent validity (Crocker et al., 2003; Park null findings, gender was treated as a covariate to be consist- & Crocker, 2008). These psychometric properties were also ent with previous research (Baker & McNulty, 2011; Neff maintained for the specific subscales of god’s love and fam- & Beretvas, 2013). ily support, and there were no significant differences found All other covariates did demonstrate significant differ- between African Americans and individuals from other eth- ences. For homelessness, there were differences in depres- nic/racial backgrounds in terms of the psychometrics of the sive symptoms such that individuals who were homeless measure (Crocker et al., 2003). In this study, the Cronbach’s reported higher levels of depressive symptoms (M = 34.21,

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Table 1 Demographic characteristics of the participants (N = 109) As a result, six covariates were included in the analyses to Demographic characteristics Descriptive statistics improve the precision of our estimates in the following study (Lohr, 2010; Tukey, 1991). Age (mean; SD) 37.5; 11.7 Table 3 displays the direct effects among the study vari- Gender (%) ables. As expected, experience of shame was positively asso- Male 41.3 ciated with depressive symptoms, even after controlling for Female 58.7 age, gender, relationship status, homelessness, unemploy- Relationship status (%) ment, and monthly income and, thus, the first hypothesis was In relationship 23.0 supported. Only partial support was found for the second Not in relationship 77.0 hypothesis, as findings revealed that experience of shame Have children (%) 65.1 was negatively associated with self-compassion, but not con- Homeless (%) 47.7 tingent self-worth. Similarly, only partial support emerged Unemployed (%) 89.0 for the third hypothesis, as self-compassion, but not contin- Individual monthly income gent self-worth, was negatively associated with depressive $0–$249 62.4 symptoms. $250–$499 6.4 The fourth and major hypothesis pertained to the influ- $500–$999 24.8 ence of self-compassion and contingencies of self-worth on > $999 6.4 the association between experience of shame and depressive symptoms. The mediation model was tested to determine if the association was mediated by self-compassion and/or SD = 12.07) compared to those who were not homeless self-worth contingent upon family support and God’s love (M = 27.49, SD = 14.53), (t(107) = − 2.61, p = .01). This was (as shown in Fig. 1). Thus, the following specific indirect also the case for God’s love; individuals who were home- effects were tested: (a) the indirect effect of experience of less (M = 6.25, SD = 0.91) compared to those who were not shame on depressive symptoms through self-compassion, (M = 5.66, SD = 1.63) reported higher levels of God’s love controlling for both dimensions of contingent self-worth, (t(107) = − 2.34, p = .02). Regarding employment status, (b) the indirect effect of experience of shame on depres- there were differences in reported levels of shame, such that sive symptoms through the family support dimension of individuals who were employed (M = 27.33, SD = 16.04) contingent self-worth, controlling for the indirect effects of compared to those who were not (M = 39.89, SD = 21.24) self-compassion and the God’s love dimension of contingent reported less shame (t(107) = 2.46, p = .03). Similarly, indi- self-worth, and (c) the indirect effect of experience of shame viduals who were employed reported higher levels of self- on depressive symptoms through the God’s love dimension compassion (M = 3.01, SD = 0.60) compared to their unem- of contingent self-worth, controlling for the indirect effects ployed counterparts (M = 2.60, SD = 0.57) (t(107) = − 2.38, of self-compassion and the family support dimension of con- p = .02). Concerning relationship status, there were only dif- tingent self-worth. ferences in reported levels of God’s love; individuals who Bootstrap estimates revealed a significant indirect effect were in a relationship reported higher levels of God’s love via self-compassion, (coefficient of indirect effect = 0.08, (M = 6.41, SD = 0.77) compared to those who were not in a SE = 0.03, 95% confidence interval [0.02–0.15]), as the con- relationship (M = 5.80, SD = 1.47) (t(107) = − 2.75, p = .01). fidence interval did not contain a zero. That is, as predicted, Collectively, these results provide empirical support for the self-compassion was found to be a significant mediator of the inclusion of these covariates in the subsequent analyses. experience of shame–depressive symptoms link. In others

Table 2 Demographic statistics, Mean SD α 1 2 3 4 5 6 7 Cronbach’s α, and partial correlations between variables 1. Age 37.48 11.70 – – 0.07 0.04 − 0.01 − 0.01 0.08 0.22* (N = 109) 2. Monthly income – – – – – − 0.15 − 0.23* 0.13 − 0.04 − 0.00 3. Shame 38.5 21.0 0.96 – – – 0.52** − 0.47** − 0.02 0.00 4. Depression 30.7 13.8 0.91 – – – – − 0.47** − 0.18 − 0.09 5. Self-compassion 68.6 15.2 0.74 – – – – 0.04 0.14 6. Family support 25.6 4.97 0.50 0.001 − 0.15 0.02 – – – 0.15 7. God’s love 29.7 6.8 0.87 − 0.023 − 0.14 0.19 0.14 – – –

* p ≤ .05, two-tailed. **p ≤ .01, two-tailed. Monthly income represents Spearman’s rank- order (rs) non- parametric correlation coeﬃcients

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Table 3 Direct eﬀects for the multiple mediator model with self-compassion and self-worth contingent upon family support and god’s love as the mediator and age, gender, relationship status, homelessness, unemployment, and monthly income as covariates (N = 109) Regression results B t p

1. Depression regressed on shame (c) 0.31 5.50 < .001

2. Self-compassion regressed on shame (a1) − 0.01 − 4.74 < .001

3. Family support regressed on shame (a2) − 0.00 − 0.04 > .05

4. God’s love regressed on shame (a3) − 0.00 − .25 > .05

5. Depression regressed on self-compassion controlling for family support and god’s love (b1) − 6.29 − 2.92 .004

6. Depression regressed on family support controlling for self-compassion and god’s love (b2) − 2.03 − 1.83 > .05

7. Depression regressed on god’s love controlling for self-compassion and family support (b3) − 0.61 − 0.70 > .05 8. Depression regressed on shame controlling for self-compassion, family support, and god’s love (c′) 0.23 3.94 < .001

** p ≤ .01, two-tailed. *** p ≤ .001, two-tailed

Table 4 Indirect effects of experience of shame on depressive symp- demographics in our country, persistence in healthcare dis- toms through self-compassion and self-worth contingent upon family parities in the United States, limited generalizability of cur- N support and god’s love ( = 109) rent research findings, and significant differences between Mediator Estimate SE 95% CI PM ethnoracial groups across a variety of psychological health related factors (George, Duran, & Norris, 2014). Despite Self-compassion 0.08 0.03 0.03–0.14 0.24 national initiatives to increase the number of racial and eth- Family support 0.00 0.01 − 0.02 to 0.03 0.01 nic minorities in clinical research, they remain underrepre- God’s love 0.00 0.01 − 0.01 to 0.03 0.00 sented in empirical investigations conducted in healthcare Total indirect effects 0.08 0.03 0.02–0.15 0.26 systems. Thus, one of the most significant contributions of Based on 10,000 bootstrap samples the present study is its inclusion of solely African American CI confidence interval, PM percent mediation effect size participants and its focus on resilience in this population. Age, gender, relationship status, homelessness, unemployment, and Promoting resilience in African Americans will help reduce monthly income as covariates the probability that they develop depressive symptoms (Eis- man, Stoddard, Heinze, Caldwell, & Zimmerman, 2015). words, self-compassion plays a significant role in informing The study also advances our appreciation of the pow- the association between shame and depressive symptoms. erful role that self-compassion plays in the psychological The indirect effects of shame on depressive symptoms resilience of African Americans receiving care in a medical through the family support and God’s love dimensions of setting. Specifically, the findings showed that self-compas- contingent self-worth were not statistically significant; the sion mediates the shame–depressive symptoms link. Given confidence intervals both contained zeros. That is, contrary that shame is a painful feeling of humiliation caused by the to what was hypothesized, the two dimensions of contingent awareness that one has done something wrong, whereas self- self-worth considered to be highly relevant for low-income compassion is compassion turned inward and the ability to African Americans—family support and God’s love—were hold one’s feelings of suffering with a sense of warmth, not significant mediators of the experience of shame–depres- connection, and concern (Neff, 2003b), self-compassion sive symptoms link for this sample. The effect sizes of all the appears to be a psychological resilience factor for African three and total indirect effects are shown in Table 4. Thus, Americans responding to assaults against the self (Neff the fourth hypothesis was partially supported, as self-com- & McGehee, 2010). Thus, our findings build upon recent passion, but not contingent self-worth, served to mediate studies that have found that self-compassion is a critically the significant association between experience of shame and important resilience mechanism (Trompetter et al., 2017). depressive symptoms in this clinical sample of low-income Self-compassion may be a potential buffer against depres- African Americans. sive symptoms (MacBeth & Gumley, 2013) because of its inverse relationship to self-criticism (Neff, 2003a). Self- criticism is a central aspect of shame and reflects internal Discussion shaming (Pinto-Gouveia, Castilho, Matos, & Xavier, 2013). Thus, the mediating role of self-compassion on the relations The importance of conducting research in medical set- between shame and depressive symptoms could be inter- tings focused specifically on racial and ethnic minority preted through each constructs’ association with self-criti- populations has been well established given the shifting cism. Specifically, as shame increases so does self-criticism

1 3 Journal of Clinical Psychology in Medical Settings and this could explain the subsequent decrease in self-com- depressive symptoms was a surprise, as fluctuations in self- passion. Self-criticism has been found to be another media- worth have been found to be associated with negative emo- tor of the shame–depressive symptom link, and it may be tionality, negative self-evaluation, and depressive symptoms that this construct acts in connection with self-compassion in other studies with mixed samples (Crocker, 2002; Sargent, to explain the shame–depressive symptom linkage (Pinto- Crocker, & Luhtanen, 2006). One possible explanation for Gouveia et al., 2013). the lack of associations is that in our study population, the Study results also bolster our understanding of the asso- fluctuation of a sense of self-worth triggered by alterna- ciations among shame, depressive symptoms, and self-com- tions between successes and failures weakened its associa- passion in African Americans receiving behavioral health tions with shame and depressive symptoms. Additionally, services in a medical setting following a suicide attempt. there could be wide variation in individuals’ beliefs about In keeping with the literature documenting a strong asso- the importance of God’s love, possibly contributing to the ciation between shame and depressive symptoms (Andrews lack of association. Before firm conclusions can be drawn et al., 2002; Kim et al., 2011; Pinto-Gouveia & Matos, about the lack of the interrelations among these variables in 2011; Robinaugh & McNally, 2010), this study is the first African Americans, more studies with similar findings need to demonstrate this connection in African American adults. to occur. It was also surprising that contingent self-worth The shame–depressive symptom link may be particularly did not serve as a mediator between shame and depressive powerful for African Americans, given that shame is a com- symptoms. This may be attributable to the fact that contin- mon response to the oppression and discrimination that they gent self-worth is a conditional construct and its level is have experienced (Carr, Szymanski, Taha, West, & Kaslow, dependent upon unstable factors, such as relationships with 2014). In addition, feelings of shame related to concerns others and one’s performance (Crocker & Knight, 2005). about stigma often reduce African Americans’ willingness to Moreover, although successes in specific domains of con- seek formal behavioral health services (Lucea et al., 2013). tingent self-worth may boost one’s self-esteem, failures may The finding that shame is inversely associated with self- lead to an internalized sense of worthlessness and feelings compassion is relatively novel. Only a limited number of of shame and depressive symptoms. For example, if family studies examine this direct association (Barnard & Curry, support is unstable, individuals’ sense of self-worth based 2012; Kelly, Carter, Zuroff, & Borairi, 2013; Reid, Temko, upon family support might reflect more of the fluctuation of Moghaddam, & Fong, 2014; Reilly, Rochlen, & Awad, 2014) family support, instead of a stable trait that can have a close and none have included a significant sample of African association with people’s internal experiences. A second Americans or individuals being assessed in medical settings. possible explanation for the null finding may be challenges The inverse relation between shame and self-compassion is with measurement, namely the low internal consistency of conceptually understandable; shame is characterized by neg- the family support factor of the contingent self-worth meas- ative self-evaluation, self-criticism, and worthlessness (Kim ure. Third, it is possible that contingent self-worth does not et al., 2011), whereas self-compassion is characterized by explain the relation between the experience of shame and self-acceptance regardless of external factors (Neff, 2003a). depressive symptoms in low-income African Americans. Not surprisingly, and consistent with the literature Indeed, no theoretical evidence suggests that shame would (Krieger et al., 2013; MacBeth & Gumley, 2013; Van Dam, be an upstream predictor of contingent self-worth; rather, Sheppard, Forsyth, & Earlywire, 2010), self-compassion the data indicate that shame can be a product of one not was significantly and negatively associated with depressive meeting certain contingencies (Crocker & Parker, 2004). symptoms in this sample of low-income African Ameri- Other explanations might include the concept that treatment cans who presented to the hospital after a suicide attempt. seeking could be a buffer for negative self-worth, explaining Although the finding in this study is cross-sectional, there the lack of correlations and that initiating treatment itself is evidence that self-compassion prospectively predicts might feel like a success, or that through the act of treatment changes in depressive symptoms (Raes, 2011). Our findings seeking family support is elicited (even if it’s temporary). add to the growing evidence supporting the notion that self- Lastly, contingent self-worth may be serving an experiential compassion is an important resilience factor when it comes avoidant function in that by having a heightened focus on to depressive symptoms (MacBeth & Gumley, 2013). The personal successes and failures, people are not as attuned to results also suggest that among African Americans, similar their own emotional experiences or as aware of their depres- to individuals from other ethnic/racial groups, self-compas- sive symptoms. sion is invaluable for psychological well-being. There are several limitations to this study that must be Counter to what was predicted, no significant associations considered when considering the findings that emerged. were found among shame, contingent self-worth based on First, the sample was primarily representative of low- family support and God’s love, and depressive symptoms. income African Americans with histories of suicide The lack of association between contingent self-worth and attempts, which raises questions about the generalizability

1 3 Journal of Clinical Psychology in Medical Settings of the findings to more diverse African American sam- In terms of clinical implications, interventions that ples or to other racial/ethnic or socioeconomic groups. directly aim to reduce shame are warranted for myriad More work is needed to replicate these analyses in other problems and populations (Kim et al., 2011). Results of populations of differing racial/ethnic, social class, and this investigation support this treatment recommendation clinical backgrounds to determine the extent to which self- for suicidal low-income African Americans, particularly compassion significantly explains the shame–depressive those who endorse depressive symptoms. Moreover, the symptoms link. Second, other important mediators related mediational finding that self-compassion mediates the rela- to shame and depressive symptoms (e.g., rumination, self- tion between shame and depressive symptoms sheds light criticism) were not included and therefore it is not known on a potential intervention target for individuals who have how these constructs would collectively explain the con- high levels of shame and depressive symptoms. There is nection between the two primary constructs of interest. burgeoning evidence in support of self-compassion-based Third, the cross-sectional nature of the design does not interventions for preventing and ameliorating psychopathol- allow for the establishment of causality among the con- ogy, including depressive symptoms (Brooks, Kay-Lambkin, structs of the experience of shame, self-compassion, and Bowman, & Childs, 2012; Kelly et al., 2013; Noorbala, Bor- depressive symptoms. Although theoretical and empiri- jali, Ahmadian-Attari, & Noorbala, 2013; Webb & Forman, cal evidence has supported the impact of shame and self- 2013; Werner et al., 2012; Wren et al., 2012). Data also compassion on the development of depressive symptoms, indicate that self-compassion is a valuable emotion regula- it is difficult to discern whether self-compassion serves to tion strategy for individuals with elevated depressive symp- mediate the link between shame and depressive symptoms toms (Diedrich, Grant, Hofmann, Hiller, & Berking, 2014). or between depressive symptoms and shame based on the Moreover, incorporating self-compassion training into other current cross-sectional dataset. Future work should collect evidence-based interventions appears to enhance their effec- longitudinal data on shame, self-compassion, and depres- tiveness in terms of the amelioration of psychological diffi- sive symptoms at multiple time points to determine the culties, such as depressive symptoms (Hofmann, Grossman, causal pathway of these three variables, so that the cur- & Hinton, 2011). In addition, compassionate mind training rent mediational hypotheses can be tested more rigorously. is effective with people with high shame and who engage Finally, given the large number of covariates included and in self-criticism (Gilbert et al., 2012; Lucre & Corten, the fact that the effect sizes obtained were in the small to 2013). Thus, interventions that include a major component medium range, until the results are replicated, the stability focused on self-compassion training should be developed, of the findings remains an empirical question. implemented, and evaluated for individuals with elevated Despite the aforementioned limitations, results of this levels of shame and depressive symptoms. Targeting self- study have multiple implications. With regard to research compassion as a resilience mechanism may serve to interfere implications, the findings add to the list of constructs found with a key element of shame (self-criticism), lead to a reduc- to mediate the well-established relation between shame and tion in self-blaming for negative thoughts and an increase in depressive symptoms (Pinto-Gouveia & Matos, 2011). It feelings of self-acceptance, which in turn can result in lower will be helpful for future work to identify other resilience levels of depressive symptoms. Such compassion-based mechanisms that may account for this association and deter- intervention approaches, particularly if they build upon the mine if they act in parallel or sequentially. For example, burgeoning literature on using a resilience framework to symptom-focused rumination (i.e., focused attention on the guide intervention development and implementation, may symptoms of one’s distress) has been found to mediate the be effective with African Americans with elevated levels of link between self-compassion and depressive symptoms; shame and depressive symptoms at high risk for difficulties therefore, self-compassion and symptom-focused rumina- such as those with a recent suicide attempt (Chmitorz et al., tion may mediate the relation between shame and depres- 2018). In addition, these interventions need to be created sive symptoms in a sequential fashion (Krieger et al., 2013). in a fashion that takes into account depressed individuals’ In addition, it will be important to examine the linkages challenges with feeling compassionate toward themselves in this study in other ethnic/racial and social class groups (Pauley & McPherson, 2010). Finally, such interventions to determine the generalizability of the results across sam- must be adapted for use with the target population, in this ples. Further, given the suggestion in the literature that the case low-income African Americans (Dutton, Bermudez, gender differences in self-compassion may be particularly Matas, Majid, & Myers, 2013; Sobczak & West, 2013; pronounced about ethnic minority samples (Yarnell et al., Woods-Giscombé & Black, 2010). 2015), the strength of the link between both shame and self- compassion and self-compassion and depressive symptoms Acknowledgements This work was supported by Emory University Research Council under a grant (Group interventions for Suicidal Afri- should be examined separately for African American males can American men and women) awarded to the last author (Kaslow). and females.

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