Mechanisms Underlying the Link Between Child Maltreatment Severity and Psychological Distress in College Women

Mindfulness (2020) 11:1446–1459 https://doi.org/10.1007/s12671-020-01361-2

ORIGINAL PAPER

Self-compassion and Fear of Self-compassion: Mechanisms Underlying the Link between Child Maltreatment Severity and Psychological Distress in College Women

Terri L. Messman-Moore1 & Prachi H. Bhuptani1

Published online: 17 April 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract Objectives Women are at increased risk for depression and anxiety associated with child maltreatment, given higher rates of exposure to childhood maltreatment and a greater sensitivity resulting in maltreatment-related distress. Thus, there is a need to identify mechanisms of resilience among female survivors of child maltreatment. Self-compassion may promote resilience, whereas fear of self-compassion may diminish this protective effect. Moreover, distinct facets of self-compassion (e.g., self- kindness) versus self-coldness (e.g., self-judgment) may differentially explain risk or resilience for child maltreatment outcomes. Methods College women (N = 586) completed anonymous online surveys assessing the severity of different types of child maltreatment, self-compassion, fear of self-compassion, depression, anxiety, and stress. Results Severity of sexual, physical, and emotional abuse, and emotional and physical neglect, was positively associated with elevated fear of self-compassion and the absence of self-compassion (i.e., self-coldness). In contrast, emotional abuse and neglect severity were the only maltreatment variables negatively associated with self-compassion. Models indicated an indirect relation between increased maltreatment severity and heightened psychological distress via fear of self-compassion and self-coldness (i.e., isolation, overidentification). Statistical patterns indicative of suppression among the positive facets of self-compassion occurred. Conclusions The centrality of emotional maltreatment, along with fear of self-compassion, isolation, and overidentification, emerged across analyses. Findings suggest the absence of self-compassion (i.e., self-coldness) is associated with specific forms of distress. Additional research with child maltreatment survivors should examine self-compassion components rather than a unidimensional construct.

Keywords Child abuse . Child neglect . Self-compassion . Depression . Anxiety . Stress

A meta-analysis of longitudinal studies demonstrated that diagnoses (Teicher and Samson 2013). Exposure to childhood experiencing child maltreatment is associated with increased maltreatment and negative outcomes associated with it differ risk of depression and anxiety in adulthood, with the magnitude according to the victim’s gender. In the NESARC study of of risk varying by maltreatment type (e.g., odds ratios ranged 34,653 US adults, women had significantly higher rates of from 1.7 for neglect to 2.7 for sexual abuse) (Li et al. 2016). childhood physical, sexual, and emotional abuse compared Maltreated individuals diagnosed with depressive or anxiety with men (Hartford et al. 2014). Research considering the co- disorders have an earlier age of onset, greater symptom severity, existence of different types of childhood maltreatment indicates more comorbidity, greater risk for suicide, and poorer treatment women experience higher rates of child emotional abuse, emo- response than non-maltreated individuals with the same tional neglect, and sexual abuse, and higher rates of physical abuse in the context of emotional or sexual abuse compared with men (Rehan et al. 2017; Scher et al. 2004; Taillieu et al. * Terri L. Messman-Moore 2016). Thus, women are more likely than men to experience [email protected] multiple types of child maltreatment, and also experience higher rates of most forms of child maltreatment in isolation. 1 Department of Psychology, Miami University, Oxford, OH 45056, Psychiatric correlates of child maltreatment also vary by USA gender, with women more sensitive to the negative impact Mindfulness (2020) 11:1446–1459 1447 of childhood maltreatment. Among college students exposed individual’s experience at any one point in time; rather self- to childhood maltreatment, a greater proportion of women compassion is experienced in the absence of self-coldness or show poor psychological adjustment compared with men vice versa, from moment to moment. For assessment, Neff (35.2% vs. 17.6%) (Maples et al. 2014). Moreover, among operationalized these bipolar dimensions into six separate adults reporting childhood sexual abuse, emotional neglect, facets of self-compassion, three of which assess a compassion- and physical neglect, women are more likely than men to be ate approach to one’s suffering (i.e., self-kindness, common diagnosed with clinically elevated levels of depression and humanity, and mindfulness) and three of which assess a harsh anxiety (Rehan et al. 2019). There also is evidence that fe- and critical attitude towards oneself (i.e., self-judgment, isola- males are negatively affected by less severe child maltreat- tion, and overidentification). Self-kindness involves the ten- ment. Among female, compared with male, adolescents, child dency to be caring and understanding in the context of diffi- emotional maltreatment had a more severe negative impact on culties or failure, in contrast to self-criticism, self-condemna- symptoms of depression and anxiety at lower levels of abuse tion, blaming, and rumination, which are associated with de- severity (Hagborg et al. 2017). In sum, the threshold for dis- pression and other forms of psychopathology (Van Dam et al. tress associated with child maltreatment is lower among ado- 2011). Common humanity reflects our ability to recognize our lescent females, as less severe levels of maltreatment are re- struggles as an inherently universal aspect of the human ex- quired to trigger depression and anxiety. These findings indi- perience, in contrast to feelings of isolation upon perceiving cate a need for additional research focused on factors that one’s struggles as unusual, abnormal, or uncommon. Finally, explain the impact of child maltreatment on women, given mindfulness is one aspect of self-compassion which involves gender disparities in exposure to, and outcomes associated a stance of equanimity towards difficult and uncomfortable with, child maltreatment. Self-compassion may be such a experiences, rather than overidentifying with, or fixating up- mechanism. on, such difficulties (Van Dam et al. 2011). High levels of self-compassion are associated with lower The buffering impact of self-compassion is argued to occur rates of depression, anxiety, and general stress (MacBeth and because its components (e.g., self-kindness) shift cognitive Gumley 2012). Initial longitudinal studies suggest a buffering factors associated with stress and anxiety, such as self-blame effect of self-compassion on depression, with improvement in and rumination (Van Dam et al. 2011). Yet, research to date self-compassion leading to decreases in depression (Krieger primarily focuses on an overarching self-compassion con- et al. 2016). Diminished self-compassion as well as elevations struct. The overarching concept of self-compassion is com- in shame and self-criticism explains higher rates of depres- prised of the presence of positive self-compassion facets sion, anxiety, and stress associated with child maltreatment (e.g., self-kindness) and the absence of the negative facets (Naismith et al. 2019;Rossetal.2019). Self-compassion (i.e., self-coldness). However, the measurement of self- may be one mechanism that underlies resilience following compassion with the Self-Compassion Scale, an instrument exposure to child maltreatment because it promotes effective developed by Neff (2003), uses reverse-scored self-coldness emotion regulation among female survivors of interpersonal items, which may artificially inflate the negative association violence (Scoglio et al. 2018), and mediates the link between between self-compassion and psychological distress. More child maltreatment and emotion dysregulation (Reffi et al. research is needed to determine whether facets of self- 2019). Moreover, lack of self-compassion explains the signif- compassion show this buffering effect. This is especially per- icant association between child maltreatment and heightened tinent given that self-coldness (i.e., self-judgment, isolation, internalized shame (Ross et al. 2019). Self-compassion is as- and overidentification) shows stronger relations with distress sociated with transdiagnostic mechanisms such as shame and than positive self-compassion facets (e.g., self-kindness), self-criticism (MacBeth and Gumley 2012), which underlie which show weak or negligible associations with psychopa- risk for numerous psychiatric outcomes. Importantly, self- thology (Körner et al. 2015; López et al. 2018). compassion is amenable to change (Fritz et al. 2018; Wilson The seeds of self-compassion are planted in early child et al. 2019). relationships with caregivers and attachment figures (Gilbert Self-compassion involves treating oneself with kindness and Procter 2006; Ross et al. 2019). Because of this, self- and encouragement, and the tendency to be warm, caring, compassion may be compromised among children who grew and understanding in the face of personal difficulties (López up in environments lacking adequate warmth and compassion. et al. 2018; Muris and Petrocchi 2017;Neff2003). One of the Indeed, diminished self-compassion is associated with critical most widely adopted definitions of self-compassion in the parents, familial dysfunction, and child maltreatment research literature was developed by Neff (2003), who con- (Naismith et al. 2019; Vettese et al. 2011;Wuetal.2018). ceptualized self-compassion as consisting of two core dimen- Children who experience verbal or emotional abuse by par- sions. These two dimensions reflect opposite poles that signify ents, including being called names such as “stupid” or “bad,” either the presence of self-compassion or its absence (e.g., appear especially vulnerable to developing self-criticism self-coldness). These opposite poles do not coexist within an (Naismith et al. 2019; Sachs-Ericsson et al. 2006). Yet few 1448 Mindfulness (2020) 11:1446–1459 studies focus specifically on the association between child development of fears of rejection and internalized harsh criti- maltreatment (abuse or neglect) and self-compassion. Most cism, as well as a feeling of being underserving of compassion studies that do examine this connection demonstrate that child (from others and the self). Such experiences may cultivate fear maltreatment is associated with decreased self-compassion and a lack of perceived safety in abuse survivors, and (Miron et al. 2016;Rossetal.2019; Tanaka et al. 2011; compassionate acts from others or towards the self may Vettese et al. 2011;Wuetal.2018), and that such relations trigger this sense of vulnerability. Gilbert and Procter (2006) are particularly pronounced for emotional abuse and emotion- noted, “…such individuals often come from neglectful or trau- al neglect. For example, in a study of 117 youth in foster care matic backgrounds and have rarely felt safe or reassured. (Tanaka et al. 2011), self-compassion was significantly lower Indeed, we have found that feelings of warmth or gentle reas- among survivors of child physical and emotional abuse (and surance were often frightening for them” (p. 355). physical and emotional neglect), although emotional abuse Importantly, fear of self-compassion is not synonymous was the only type of maltreatment associated with self- with self-coldness (e.g., self-criticism) or a lack of skill in compassion in multivariate models. In a sample of Chinese self-compassion; it is a fearful reaction or avoidance of the college students, only emotional maltreatment (abuse and ne- provision of self-compassion, due to the negative associations glect) was associated with self-compassion in a model that described earlier. Fear of self-compassion explains the associ- included all forms of child maltreatment (Wu et al. 2018). ation between child maltreatment and posttraumatic stress dis- Similarly, among female US college students, childhood emo- order (PTSD) as well as depression (Boykin et al. 2018;Miron tional abuse, but not sexual or physical abuse, was associated et al. 2016). Moreover, in models examining both self- with self-compassion (Miron et al. 2014). Together, these compassion and fear of self-compassion, only fear of self- studies suggest emotional maltreatment has a more significant compassion was directly associated with child sexual abuse, role in development of self-compassion (or lack thereof) than and mediated the association between sexual abuse and dis- other types of maltreatment. tress (depression and PTSD symptoms). Although both self- Several studies documenting an association between child compassion and fear of self-compassion are associated with maltreatment and self-compassion focus on female college child maltreatment, fear of self-compassion may show a stron- students (Boykin et al. 2018; Miron et al. 2014; Miron et al. ger connection to psychopathology outcomes. 2016), linking child maltreatment, lower self-compassion, and There is evidence that self-compassion is a mechanism that negative outcomes such as problematic alcohol use, posttrau- explains child maltreatment outcomes. Low levels of self- matic stress symptoms, and depression. Such findings suggest compassion explain the association of child maltreatment self-compassion may be a particularly appropriate target for and negative outcomes, including the link between juvenile women. Additional research is needed to focus on self- victimization (e.g., exposure to community violence and compassion among women, especially considering that fe- crime, bullying, and child maltreatment) and psychological males (adolescents and women) report lower levels of self- distress (Játiva and Cerezo 2014), as well as between child compassion than males (Bluth et al. 2017; Yarnell et al. maltreatment and emotion dysregulation (Reffi et al. 2019; 2015). Moreover, women are more likely to employ negative Vettese et al. 2011). More specifically, low self-compassion cognitive emotion strategies, such as self-blame, suppression, mediates the association between child emotional maltreat- rumination, and catastrophizing (Nolen-Hoeksema and Aldao ment (emotional abuse or neglect) and depressive symptoms 2011), that can be ameliorated by increasing self-compassion. in Chinese college students and adult community members in Fear of self-compassion is also relevant to distress among the Southwestern United States (Ross et al. 2019;Wuetal. child maltreatment survivors. Even if survivors of maltreat- 2018). Only two studies have examined the severity of child ment understand how to engage in self-compassion, there are maltreatment in relation to self-compassion (Tanaka et al. barriers to doing so. Collectively referred to as fear of self- 2011;Wuetal.2018). However, a focus on severity is impor- compassion, such beliefs include thinking that self- tant given that abuse severity (versus presence) is one of the compassion would make one weak or vulnerable to others, single best predictors of psychological distress such as PTSD or that it would lower one’s standards and reveal one’sflaws and depression (Bifulco et al. 2002; Evans et al. 2013). or inadequacies, or that one is underserving of self-compas- The overarching purpose of the current investigation was to sion. Experiences of child abuse and neglect contribute to expand our understanding of self-compassion in relation to such belief systems that interfere with the capacity for self- child maltreatment. Assessment of maltreatment severity, compassion, culminating in a fear of self-compassion (Gilbert rather than the presence of abuse, allows for a more nuanced et al. 2011). Factors that contribute to fear of self-compassion understanding of the association between child maltreatment include increased sensitivity to threat, critical self-beliefs, and and self-compassion. We hypothesized self-compassion, self- extensive shame (Gilbert and Procter 2006;Rossetal.2019). coldness, and fear of self-compassion would mediate the rela- Early interpersonal trauma (e.g., child abuse and neglect, pa- tion between child maltreatment severity and distress. rental criticism, or peer bullying) is highly salient to Specifically, we expected that increased severity of all types Mindfulness (2020) 11:1446–1459 1449 of child maltreatment would be significantly associated with score. Example items include the following: “Someone tried lower self-compassion, but that the strongest relations would to touch me in a sexual way, or tried to make me touch them” emerge for emotional maltreatment (emotional abuse and ne- (sexual abuse), “People in my family called me things like glect). We hypothesized that child maltreatment severity “stupid,”“lazy” or “ugly”” (emotional abuse), “People in would be positively associated with self-coldness (i.e., nega- my family hit me so hard that it left me with bruises or marks” tive components of self-compassion: self-judgment, isolation, (physical abuse), “There was someone in my family who and overidentification) and fear of self-compassion. helped me feel important or special” (emotional neglect, reverse scored), and “I had to wear dirty clothes” (physical neglect). The CTQ is a widely used screener for child maltreat- Method ment, but does not specifically assess abusive acts. Comparisons of the CTQ and behaviorally derived assessment Participants showed high levels of agreement (92.4% for sexual abuse and 80% for physical abuse), although the CTQ identified higher Participants were 586 female undergraduates at a mid-sized rates of sexual abuse and lower rates of physical abuse com- public university in the Midwestern United States, ages 17–26 pared with a computer-administered interview that assessed (mean age = 18.71, SD = 0.97). The vast majority were child maltreatment (DiLillo et al. 2010). In the current study, Caucasian (85.5%), with an additional 10.4% Asian, 4.9% subscales generally demonstrated good internal consistency; Black, 1.9% biracial, and 0.9% Pacific Islander; 5.5% identi- Cronbach’s alpha ranged from .80 to .92, with the exception of fied as Latina/Hispanic. The majority were from upper-middle physical neglect (Cronbach’s alpha = .56), similar to that re- class households based upon reported family household in- ported by Wu et al. (2018). Three items, not used in the current comes. We recruited female college students for the study study, may assess response styles reflecting minimization. for several reasons. First, women are more likely than men to be exposed to multiple forms of child maltreatment (Rehan Self-compassion Self-compassion was assessed with the Self- et al. 2017; Taillieu et al. 2016), as well as specific forms of Compassion Scale, a 28-item questionnaire with six subscales maltreatment previously correlated with self-compassion which assesses self-compassion (self-kindness, common (e.g., Tanaka et al. 2011;Wuetal.2018), such as emotional humanity, and mindfulness) and self-coldness (self- and sexual abuse (Hagborg et al. 2017; Rehan et al. 2019). judgment, isolation, and overidentification) (Neff 2003). Second, women and female adolescents show an increased Example items include “I try to be loving towards myself risk for anxiety and depression, including major depressive when I’m feeling emotional pain” (self-kindness), or “When disorder, compared with males (Merikangas et al. 2010), and I’m feeling down I tend to obsess and fixate on everything report lower levels of self-compassion than males (Bluth et al. that’swrong” (overidentification). Response options on Likert 2017; Yarnell et al. 2015). scale range from 1 (almost never) to 5 (almost always). Subscale scores were computed by calculating the mean of Procedures subscale item responses. The SCS has good reliability and validity (Neff 2003). In the current sample, internal consisten- Participants were recruited from a research participant pool cy Cronbach’s alpha for subscales were good, and ranged (for Introduction to Psychology), and earned research credit from .82 to .87. for study completion. Informed consent was obtained from all participants included in the study. All participants met in the Fear of Self-compassion Fear of self-compassion was assessed laboratory for informed consent/study instructions, but com- with the Fear of Compassion Scales-Self-Compassion (FSC- pleted the online surveys outside the laboratory. Participant SC), a 15-item questionnaire (Gilbert et al. 2011). Example data were tracked with a unique identification number. No items include “I feel that I don’t deserve to be kind and for- adverse effects were reported. giving to myself,” or “IfearthatifIammoreself- compassionate I will become a weak person.” Responses are Measures on a Likert scale, indicating degree of agreement with each statement on a scale ranging from 0 (“do not agree at all”)to4 Child Maltreatment The Childhood Trauma Questionnaire (“completely agree”). Higher scores indicate greater fear of (CTQ), a 28-item questionnaire, was used to assess five types self-compassion. Internal consistency in the current sample of child maltreatment severity: sexual abuse, physical abuse, was good (Cronbach’salpha=.95). emotional abuse, physical neglect, and emotional neglect (Bernstein and Fink 1998). Each subscale is comprised of five Psychological Distress Depression, anxiety, and stress were items with responses ranging from 1 (never true) to 5 (very assessed with three subscales of the DASS-21, a 21-item sur- often true); severity was measured with the continuous sum vey (Lovibond and Lovibond 1995). Example items include 1450 Mindfulness (2020) 11:1446–1459

“I felt that I had nothing to look forward to” (depression), “I individual pathways, consistent with current recommenda- felt scared without any good reason” (anxiety), and “Itended tions (e.g., Hayes 2013). Specifically, we tested the overall to overreact to situations” (stress). Each subscale is comprised indirect effect for each model (e.g., child emotional abuse of seven items, with responses rated on a 4-point Likert scale severity → facets of self-compassion, self-coldness, and fear ranging from 0 (“did not apply all”)to3(“applied to me very of self-compassion → depression, anxiety, and stress) and much, or most of the time”) with a focus on the previous week. used bootstrapping techniques to construct confidence inter- Higher scores are indicative of greater distress. In the current vals around the indirect effects (Hayes 2013; Preacher and study, internal consistency was good for each of the subscales, Hayes 2004) (see Fig. 1). Path analysis in MPlus allows for with Cronbach’s alpha ranging from .83 (anxiety) to .90 (de- multiple simultaneous parallel mediators in the same model pression). Above-threshold scores on the DASS-21 are asso- and provides magnitude as well as significance of the indi- ciated with corresponding DSM-5 diagnostic conditions in rect effect via each mediator. Missing Value Analysis college students (Bravo et al. 2018). (MVA) in SPSS revealed missing values ranging from 0.2 to 1% across key study variables. Little’s MCAR test (Little 1988) indicated that data were not significantly different χ2 Results from the missing completely at random pattern ( (11) = 6.05, p =.53).Basedonguidelinestomanagelessthan2% missing data, single imputation was used (Widaman 2006). Data were examined for normality, completeness, and the presence of outliers or impossible values. Bivariate correlations were computed to examine general patterns of associ- Bivariate Associations ation. Path analysis using the maximum likelihood estima- tion method in MPlus version 7.3 tested five distinct paral- As hypothesized, all forms of child maltreatment severity lel mediation models, one for each childhood maltreatment were associated positively with psychological distress (i.e., type. Given the overlap between the distinct forms of psy- depression, anxiety, stress) and fear of self-compassion (see chological distress, error variances for the three dependent Table 1). Only certain types of maltreatment severity were variables (depression, anxiety, and stress) were correlated. associated with self-compassion. Child emotional maltreat- Similarly, the error variances for the mediators were corre- ment severity (emotional abuse and emotional neglect) lated as they shared overlap. We tested the hypothesized showed the strongest correlations to SCS subscales. indirect effect of facets of self-compassion, self-coldness, Emotional abuse and neglect severity and physical abuse se- and fear of self-compassion, in addition to focusing on verity were positively associated with self-coldness (e.g.,

Fig. 1 Overarching model to test indirect effects of self-compassion facets and fear of self-compassion as mediators of the link between child maltreatment severity and psychological distress. Five independent models were were conducted, one for each type of maltreatment iduns 22)11:1446 (2020) Mindfulness –

Table 1 Bivariate correlations 1459

EA EN PA PN SA SK CH MD SJ IS OI FSC Depression Anxiety Stress

EA - .62*** .53*** .43*** .27*** − .13** − .02 − .07 .29*** .31*** .29*** .39*** .38*** .36*** .38*** EN - - .47*** .59*** .24*** − .20*** − .13** − .13** .18*** .21*** .16*** .40*** .34*** .29*** .26*** PA - - - .49*** .34*** − .01 .04 − .02 .09* .12** .10* .20*** .23*** .23*** .17*** PN - - - - .34*** − .08 − .02 − .06 .07 .08* .08* .28*** .20*** .19*** .16*** SA - - - - - − .04 .02 .02 .07 .04 .04 .20*** .11** .12** .07 SK ------.69*** .78*** − .31*** − .22*** − .21*** − .31*** − .23*** − .13*** − .17*** CH ------.75*** − .09 − .02 − .01 − .12*** − .09** − .01 − .02 MD------− .14** − .15*** − .17*** − .22*** − .21*** − .14** − .18*** SJ ------.80*** .82*** .50*** .47*** .43*** .50*** IS ------.81*** .51*** .52*** .42*** .51*** OI------.48***.47*** .45*** .54*** FSC------.52*** .46*** .46*** Dep ------.65*** .74*** Anx ------.71*** Stress------% 30.9% 27.5% 11.9% 21.8% 9.4% Mean 8.01 8.01 5.98 6.37 5.50 2.80 2.85 2.97 3.07 2.91 2.89 11.88 7.84 7.50 11.15 SD 3.87 3.66 2.37 2.41 2.00 0.91 0.94 0.88 1.05 1.02 1.00 12.91 8.72 7.90 8.80 Range 20 20 20 17 20 4.80 4.50 4.25 4.60 4.75 4.00 57.39 42.00 42.00 42.00

*p < .05, **p < .01, and ***p < .001. EA emotional abuse severity, EN emotional neglect severity, PA physical abuse severity, PN physical neglect severity, SA sexual abuse severity, SK self-kindness, CH common humanity, MD mindfulness, SJ self-judgment, IS isolation, OI overidentification, FSC fear of self-compassion, Dep DASS-Depression, Anx DASS-Anxiety, Stress DASS-Stress, % prevalence (presence/absence) of maltreatment (mild, moderate, or severe abuse/neglect) 1451 1452 Mindfulness (2020) 11:1446–1459 isolation), and emotional neglect severity was negatively as- The Role of Self-coldness sociated with self-compassion (self-kindness, common humanity, and mindfulness). Sexual abuse and physical neglect Three facets of self-coldness were examined: self-judgment, severity showed little to no association with self-compassion. isolation, and overidentification. Self-judgment was a significant mediator of the relationship between (a) emotional abuse and anxiety, (b) emotional neglect and anxiety, and (c) phys- Suppression ical abuse and anxiety (see Table 2). In all these models, increased childhood abuse and neglect severity were associated We noted potential multicollinearity due to high correlations with higher self-judgment, which in turn was associated with among some facets of self-compassion (see Table 1). In higher anxiety. After mindfulness was removed from the me- initial mediation models, there was evidence of suppression, diation models, self-judgment was no longer a significant me- with the direction of correlations switching in the multivar- diator. Isolation was a significant mediator of the relationship iate model compared with bivariate correlations. between (a) emotional abuse and depression, (b) emotional Specifically, common humanity and self-kindness were cor- neglect and depression, (c) emotional neglect and stress, (d) related negatively with psychological outcomes at the bivar- physical abuse and depression, (e) physical abuse and stress, iate level, yet showed a positive relation with these out- (f) physical neglect and depression, and (g) physical neglect comes (b paths) in the presence of other variables. To ad- and stress (see Table 2). In all these models, increased child- dress this issue, we conducted an additional set of analyses hood abuse and neglect severity were associated with higher with models that excluded mindfulness given its high cor- isolation, which in turn was associated with higher depression relations with the other two positive subscales, and com- and stress. After mindfulness was removed from the models, pared the patterns to determine the impact of suppression these results remained unchanged, except isolation emerged as on the models based upon recommendations by Beckstead a significant mediator of the relationship between emotional (2012). Both sets of results are presented below. abuse severity and stress. Overidentification was a significant mediator of the relationship between (a) emotional abuse and anxiety, (b) emotional abuse and stress, (c) emotional neglect The Role of Self-compassion and anxiety, (d) emotional neglect and stress, (e) physical abuse and anxiety, and (f) physical abuse and stress (see Three facets of self-compassion were examined: self-kind- Table 2). In all these models, increased childhood abuse and ness, common humanity, and mindfulness. Self-kindness neglect severity were associated with increased overidentifi- was a significant mediator of the relationship between (a) cation, which in turn was associated with increased anxiety emotional abuse and anxiety, (b) emotional neglect and anxi- and stress. After mindfulness was removed from the models, ety, and (c) emotional neglect and stress (see Table 2). In all results remained largely unchanged, except overidentification these models, increased severity of childhood emotional abuse emerged as a significant mediator of the relationship between and emotional neglect was associated with lower self-kind- physical neglect and anxiety. ness. However, higher self-kindness was associated with higher anxiety and stress. To address suppression effects, mindfulness was removed from the models, after which self- The Role of Fear of Self-compassion kindness was no longer a significant mediator. Common humanity was a significant mediator of the relationship between Fear of self-compassion mediated the relationship between (a) emotional neglect and anxiety and (b) emotional neglect (a) emotional abuse and depression, (b) emotional abuse and stress (see Table 2). In these models increased severity of and anxiety, (c) emotional abuse and stress, (d) emotional emotional neglect was associated with lower common human- neglect and depression, (e) emotional neglect and anxiety, ity. Further, higher levels of common humanity were associ- (f) emotional neglect and stress, (g) physical abuse and ated with increased anxiety and stress. After mindfulness was depression, (h) physical abuse and anxiety, (i) physical removed from the models, common humanity was no longer a abuse and stress, (j) physical neglect and depression, (k) significant mediator. Mindfulness was a significant mediator physical neglect and anxiety, (l) physical neglect and stress, of the relationship between (a) emotional neglect and depres- (m) sexual abuse and depression, (n) sexual abuse and anx- sion, (b) emotional neglect and anxiety, and (c) emotional iety, and (o) sexual abuse and stress (see Table 2). In all neglect and stress (see Table 2). In all models greater severity these models, increased severity of childhood maltreatment of emotional neglect was associated with decreased mindful- was associated with increased fear of self-compassion, ness, which in turn was associated with higher depression, which in turn was associated with higher depression, anxi- anxiety, and stress. ety, and stress. After mindfulness was removed from the models, results remained unchanged. Mindfulness (2020) 11:1446–1459 1453

Table 2 Mediation models for childhood maltreatment severity

Model without mindfulness

2 apath Mediator b path cpath c′ Indirect effect R b1 path Indirect effect b (S.E.) b (S.E.) b (S.E.) b (S.E.) ab (95% C.I.) b (S.E.) ab (95% C.I.)

Emotional abuse Depression − .03 (.01)** SK .63 (.63) .86 (.09)*** .39 (.10)*** − .23 (.51) − .01 (.01) CH .30 (.48) − .27 (.47) − .01 (.01) MD − 1.64 (.58)** .08 (.01)*** SJ .43 (.55) 08 (.53) .08 (.01)*** IS 2.19 (.48)*** .18 (.10 to .27) 2.25 (.49)*** .18 (.10 to .28) .07 (.01)*** OI .24 (.62) .57 (.60) 1.31 (.19)*** FSC .19 (.04)*** .24 (.14 to .38) .19 (.03)*** .24 (.14 to .38) Anxiety − .03 (.01)** SK 1.16 (.52)* .73 (.08)*** .38 (.08)*** − .03 (− .09 to − 01) .28 (.42) − .01 (.01) CH .65 (.41) .07 (.40) − .01 (.01) MD − 1.66 (.50)** .08 (.01)*** SJ 1.09 (.54)* .08 (.006 to .19) .74 (.52) .08 (.01)*** IS .01 (.46) .06 (.46) .07 (.01)*** OI 1.2 (.58)* .09 (.009 to .18) 1.5 (.56)** .11 (.03 to .21) 1.31 (.19)*** FSC .15 (.03)*** .20 (.19 to .32) .15 (.02)*** .20 (.11 to .33) Stress − .03 (.01)** SK 1.00 (.57) .86 (.09)*** .44 (.09)*** − .16 (.53) − .01 (.01) CH 1.02 (.53) .24 (.47) − .01 (.01) MD − 2.21 (.56)*** .08 (.01)*** SJ .56 (.53) .09 (.52) .08 (.01)*** IS .91 (.49) .99 (.49)* .08 (.004 to .17) .07 (.01)*** OI 2.11 (.58)*** .15 (.07 to .26) 2.57 (.57)*** .18 (.10 to .30) 1.31 (.19)*** FSC .12 (.03)*** .16 (.07 to .27) .12 (.03)*** .16 (.07 to .26) Emotional neglect Depression − .05 (.01)*** SK .70 (.62) .80 (.09)*** .37 (.11)** − .19 (.50) − .03 (.01)** CH .43 (.49) − .16 (.47) − .03 (.01)** MD − 1.68 (.58)** .05 (.01 to .13) .05 (.01)*** SJ .53 (57) .18 (.54) .06 (.01)*** IS 2.21 (.48)*** .13 (.07 to .22) 2.27 (.49)*** .13 (.07 to .22) .04 (.01)*** OI .35 (.62) .69 (.60) 1.42 (.17)*** FSC .18 (.03)*** .26 (.14 to .40) .18 (.04)*** .26 (.14 to .40) Anxiety − .05 (.01)*** SK 1.21 (.53)* .62 (.07)*** .32 (.11)** − .06 (− .14 to − .01) .32 (.43) − .03 (.01)** CH .77 (.42) − .03 (− .07 to − .001) .17 (.40) − .03 (.01)** MD − 1.6 (.51)** .05 (.01 to .12) .05 (.01)*** SJ 1.19 (.57)* .06 (.008 to .15) .83 (.54) .06 (.01)*** IS .04 (.45) .10 (.47) .04 (.01)*** OI 1.30 (.59)* .06 (.01 to .13) 1.64 (.57)** .07 (.02 to .15) 1.42 (.17)*** FSC .15 (.04)*** .21 (.11 to .35) .15 (.04)*** .21 (.11 to .36) Stress − .05 (.01)*** SK 1.01 (.58) .61 (.26)*** .25 (.09)** − .05 (− .12 to − .002) − .14 (.54) − .03 (.01)** CH 1.11 (.54)* − .04 (− .10 to − .004) .34 (.48) − .03 (.01)** MD − 2.19 (.57)*** .07 (.02 to .15) .05 (.01)*** SJ .64 (.57) .17 (.57) .06 (.01)*** IS 1.00 (.51) .06 (.004 to .14) 1.08 (.52)* .06 (.008 to .14) .04 (.01)*** OI 2.21 (.60)*** .10 (.04 to .19) 2.66 (.59)*** .06 (.05 to .22) 1.42 (.17)*** FSC .13 (.03)*** .19 (.10 to .31) .14 (.03)*** .19 (.10 to .32) 1454 Mindfulness (2020) 11:1446–1459

Table 2 (continued)

Model without mindfulness

2 apath Mediator b path cpath c′ Indirect effect R b1 path Indirect effect b (S.E.) b (S.E.) b (S.E.) b (S.E.) ab (95% C.I.) b (S.E.) ab (95% C.I.)

Physical abuse Depression − .005 (.02) SK .50 (.61) .85 (.23)*** .46 (.20)*** − .26 (.50) .01 (.02) CH .20 (.49) − .31 (.47) − .007 (.02) MD − 1.45 (.57)* .04 (.02)* SJ .53 (.57) .22 (.54) .05 (.02)* IS 2.26 (.48)*** .12 (.04 to .23) 2.30 (.49)*** .12 (.04 to .24) .04 (.02)* OI .29 (.63) .59 (.61) 1.10 (.23)*** FSC .20 (.03)*** .23 (.10 to .40) .20 (.03)*** .23 (.10 to .40) Anxiety − .005 (.02) SK 1.04 (.51)* .78 (.13)*** .49 (.12)*** .26 (.42) .01 (.02) CH .55 (.42) .03 (.40) − .007 (.02) MD − 1.48 (.50)* .04 (.02)* SJ 1.19 (.56)* .04 (.002 to .15) .89 (.54) .05 (.02)* IS .07 (.46) .11 (.46) .04 (.02)* OI 1.24 (.59)* .05 (.001 to .15) 1.54 (.57)** .06 (.006 to .17) 1.10 (.23)*** FSC .17 (.03)*** .19 (.08 to .34) .17 (.03)*** .19 (.08 to .34) Stress − .005 (.02) SK .89 (.59) .62 (.17)*** .25 (.12)*** − .19 (.54) .01 (.02) CH .97 (.50) .25 (.48) − .007 (.02) MD − 2.04 (.57)*** .04 (.02)* SJ .62 (.57) .19 (.56) .05 (.02)* IS 1.04 (.51)* .06 (.007 to .14) 1.10 (.52)* .06 (.009 to .15) .04 (.02)* OI 2.17 (.60)*** .09 (.01 to .21) 2.59 (.59)*** .11 (.01 to .24) 1.10 (.23)*** FSC .15 (.03)*** .17 (.07 to .31) .15 (.03)*** .17 (.07 to .31) Physical neglect Depression − .03 (.01) SK .56 (.63) .71 (.14)*** .27 (.16) SK − .24 (.51) − .01 (.02) CH .28 (.49) CH − .25 (.48) − .02 (.02) MD − 1.52 (.57)** MD .03 (.02) SJ .50 (.57) SJ .18 (.55) .04 (.02) IS 2.38 (.50)*** .08 (.003 to .20) IL 2.43 (.50)*** .09 (.003 to .20) .03 (.02) OI .26 (.63) OI .57 (.61) 1.51 (.25)*** FSC .20 (.03)*** .31 (.17 to .49) FC .20 (.03)*** .31 (.18 to .49) Anxiety − .03 (.01) SK 1.10 (.53)* .64 (.14)*** .30 (.15) SK .29 (.43) − .01 (.02) CH .63 (.42) CH .09 (.41) − .02 (.02) MD − 1.54 (.52)** MD .03 (.02) SJ 1.18 (.58)* SJ .85 (.55) .04 (.02) IS .19 (.48) IL .24 (.49) .03 (.02) OI 1.21 (.60)* OI 1.53 (.58)** .05 (.001 to .15) 1.51 (.25)*** FSC .17 (.03)*** .26 (.14 to .42) FC .17 (.03)*** 26 (.14 to .42) Stress − .03 (.01) SK .92 (.59) .57 (.15)*** .20 (.12) SK − .17 (.55) − .01 (.02) CH 1.01 (.54) CH .27 (.48) − .02 (.02) MD − 2.08 (.56)*** MD .03 (.02) SJ .62 (.58) SJ .18 (.56) .04 (.02) IS 1.12 (.51)* .04 (.001 to .12) IL 1.18 (.52)* .04 (.002 to .12) .03 (.02) OI 2.15 (.60)*** OI 2.57 (.59)*** 1.51 (.25)*** FSC .15 (.03)*** .23 (.12 to .38) FS .15 (.03)*** .22 (.12 to .38) Mindfulness (2020) 11:1446–1459 1455

Table 2 (continued)

Model without mindfulness

2 apath Mediator b path cpath c′ Indirect effect R b1 path Indirect effect b (S.E.) b (S.E.) b (S.E.) b (S.E.) ab (95% C.I.) b (S.E.) ab (95% C.I.)

Sexual abuse Depression − .02 (.02) SK .57 (.63) .49 (.12)** .15 (.19) − .26 (.51) .01 (.02) CH .30 (.49) − .24 (.48) .01 (.02) MD − 1.57 (.58)* .03 (.03) SJ .44 (.57) .10 (.54) .02 (.02) IS 2.38 (.50)*** 2.43 (.51)*** .02 (.03) OI .29 (.63) .61 (.61) 1.32 (.34)*** FSC .22 (.03)*** .28 (.13 to .49) .22 (.03)*** .28 (.13 to .49) Anxiety − .02 (.02) SK 1.11 (.53)* .48 (.16)** .20 (.18) .26 (.43) .01 (.02) CH .65 (.42) .09 (.40) .01 (.02) MD − 1.60 (.52)** .03 (.03) SJ 1.10 (.57) .76 (.54) .02 (.02) IS .20 (.49) .24 (.48) .02 (.03) OI 1.24 (.60)* 1.57 (.58)** 1.32 (.34)*** FSC .18 (.03)*** .24 (.11 to .42) .18 (.03)*** .24 (.11 to .42) Stress − .02 (.02) SK .91 (.60) .31 (.18) .04 (.17) − .19 (.55) .01 (.02) CH 1.03 (.54) .30 (.48) .01 (.02) MD − 2.1 (.57)*** .03 (.03) SJ .57 (.57) .13 (.55) .02 (.02) IS 1.10 (.51)* 1.17 (.52)* .02 (.03) OI 2.16 (.60)*** 2.59 (.59)*** 1.32 (.34)*** FSC .16 (.03)*** .21 (.10 to .38) .16 (.03)*** 21 (.10 to .38)

*p <.05,**p < .01, and ***p < .001. Unstarred coefficients are non-significant paths. Unstandardized coefficients and standard errors are presented. Only significant indirect effects are reported. SK self-kindness, CH common humanity, MD mindfulness, SJ self-judgment, IS isolation, OI overidentification, FSC fear of self-compassion, Depress depression

Discussion overidentification, was positively associated with depression, anxiety, and stress. In particular, isolation and overidentifica- In the current study, the association between child maltreat- tion were significant mediators of the link between child mal- ment severity and distress was explained by self-compassion treatment severity and distress, consistent with earlier studies and related variables (e.g., self-coldness, fear of self-compas- focused on depression, anxiety, or negative affect (Körner sion). As hypothesized, greater severity of maltreatment was et al. 2015; López et al. 2018; Van Dam et al. 2011). Thus, associated with lower self-compassion. Our findings are con- earlier studies documenting that self-compassion (measured sistent with earlier studies showing the strongest association with the SCS total score) mediates the link between child between emotional maltreatment (emotional abuse and ne- maltreatment and distress may instead be demonstrating that glect) and diminished self-compassion (Tanaka et al. 2011; child maltreatment is a risk factor for greater self-coldness, Wu et al. 2018). Distinct patterns emerged for different self- which promotes psychological distress, rather than self- compassion subscales, supporting recommendations to utilize compassion serving a buffering or protective effect. Future subscales of the SCS to measure self-compassion and self- studies should continue to examine the precise relations coldness rather than a total score (López et al. 2018). Child among different types of child maltreatment and different maltreatment severity (with the exception of emotional ne- components of self-compassion, to determine the extent to glect) was not associated with self-compassion (e.g., self- which child maltreatment is inversely related to self- kindness, common humanity, and mindfulness). The strongest compassion rather than positively related to self-coldness. and most consistent correlations occurred between emotional Examination of particular facets of self-compassion and abuse and neglect severity and self-coldness. self-coldness revealed distinct patterns, further supporting Self-coldness, otherwise known as the negative aspects of our suggestion to examine specific subscales of the SCS. self-compassion, including self-judgment, isolation, and Mindfulness was the only self-compassion subscale 1456 Mindfulness (2020) 11:1446–1459 associated with depression, anxiety, and stress. However, the maltreatment, especially that emotional abuse may coexist high degree of relatedness of self-compassion subscales, par- alongside more positive and caring parental interactions. In ticularly between mindfulness and self-kindness (and to a less- contrast, emotional neglect is defined by the absence of pos- er degree, common humanity), likely affected multivariate itive emotional interactions with a caregiver; therefore, this models via statistical suppression. Thus, the hallmark compo- type of maltreatment may be especially detrimental to devel- nents of self-compassion, such as self-kindness and common opment of self-compassion skills such as self-kindness and humanity, did not predict distress in multivariate models. In mindfulness. Indeed, emerging longitudinal research indicates contrast, mediation effects for self-coldness (e.g., negative that risk for depression is associated with specific symptoms, facets of self-compassion) revealed a specific pattern based such as anhedonia, that varies as a function of abuse versus upon type of distress: depression was related only to isolation, neglect (Cohen et al. 2019). anxiety was related only to overidentification, and stress was Fear of self-compassion mediated the link between child related to both overidentification and isolation. Previous stud- maltreatment severity and distress. This pattern held for all ies support this pattern, suggesting a significant association types of child maltreatment and across types of distress (e.g., between overidentification (a negative facet of self- depression, anxiety, and stress). Our findings are consistent compassion) and increased fear of negative and positive eval- with another study that reported child abuse (emotional, phys- uation among individuals diagnosed with social anxiety dis- ical, and sexual measured together as one construct) was as- order (Werner et al. 2012). Overidentification may be a par- sociated with greater fear of self-compassion, and that fear of ticularly pernicious and potentially transdiagnostic thought self-compassion predicted posttraumatic stress symptoms process that mediates the links between multiple types of child (Boykin et al. 2018). Earlier studies did not examine specific maltreatment severity and multiple outcomes (e.g., anxiety, types of child maltreatment and fear of self-compassion. Our stress). Notably, self-judgment, a variable potentially related findings suggest that regardless of type, as child maltreatment to the self-esteem criterion of chronic depression (e.g., dys- severity increases, there is also an increase in fear of being thymia), was not a significant mediator. Instead, isolation and compassionate towards oneself. However, emotional abuse overidentification, alongside fear of self-compassion, explain and emotional neglect severity show the strongest associations the link between maltreatment severity and distress, but only with fear of self-compassion. Empirical investigations are just for particular forms of child maltreatment. emerging on this topic; thus, the field needs more studies to Our findings suggest that the type of child maltreatment examine fear of self-compassion among survivors of different matters, at least in terms of associations with self- types of child abuse and neglect. However, our findings are compassion and self-coldness. Self-compassion is strongly consistent with theoretical arguments regarding child abuse and negatively associated with emotional maltreatment (par- and neglect as a pathway to fear of self-compassion (Gilbert ticularly emotional abuse). Although the negative self- and Procter 2006). compassion components (i.e., self-coldness) were linked to physical abuse severity as well, the magnitude was weaker, Limitations and Future Research and there were no links to child sexual abuse severity, consistent with earlier research that examined different forms of Our findings contribute to an emerging empirical consensus maltreatment (Miron et al. 2014; Ross et al. 2019; Tanaka regarding the deleterious impact of child maltreatment on self- et al. 2011;Wuetal.2018). Severity of emotional abuse and compassion. Several methodological strengths bolster our emotional neglect was correlated in this and other samples, confidence in the current findings, including a large sample, and the two types of maltreatment have been conceptualized inclusion of widely used and psychometrically sound mea- as a composite variable in other studies (e.g., emotional sures that facilitate direct comparisons across studies, and, maltreatment, see Wu et al. 2018). Emotional maltreatment most importantly, the investigation of a comprehensive model experiences may be more likely to involve particular elements, that examines components of self-compassion, self-coldness, such as harsh criticism or name-calling, detrimental to devel- and fear of self-compassion to identify specific predictors of opment of self-compassion (Gilbert and Procter 2006). In ad- distress. However, our results should be considered in the dition, emotional maltreatment frequently co-occurs with oth- context of several limitations, including the focus on predom- er forms of child abuse, and thus carries a potential cumulative inantly Caucasian female college students, which limits gen- impact (Edwards et al. 2003). Finally, emotional or psycho- eralization to non-college students, women of other ages, logical abuse has been posited to be a fundamental and poten- races, and ethnicities, and to men. The pattern of findings tially inseparable component of all forms of abuse and neglect reported here may also differ in other samples, particularly (Edwards et al. 2003; Ross et al. 2019); thus, this form of among community or clinical populations where the range maltreatment may be the most robust predictor of abuse- of distress levels may be wider and absolute levels of distress related outcomes because it pervades almost all types of child more severe. Research must continue to examine racial and maltreatment. This may speak to the complexity of emotional ethnic minority groups and intersectionality, factors which Mindfulness (2020) 11:1446–1459 1457 have been commonly overlooked in research on the effects of (e.g., CTQ, SCS) may lead to common method bias, which trauma and its treatment (Bryant-Davis 2019). One study could produce spurious correlations among some variables found that female African American college students had (Podsakoff et al. 2003). Most importantly, the retrospective, higher levels, and female European American college students cross-sectional design limits conclusions regarding the direc- lower levels, of self-compassion (Miron et al. 2014). We may tionality of effects as well as the causal and proximal nature of find that self-compassion operates differently among diverse relations found. It is unclear whether the presence of distress populations, interacting with strength and resilience factors affects reports of fear of self-compassion, self-compassion, such as religion and spirituality, as well as social support and and child maltreatment severity rather than vice versa. adherence to communal values. Age is another factor that may Child maltreatment predicts elevated risk of recurrent and moderate patterns reported here. In a study of depression persistent depressive episodes resistant to treatment (Nanni among individuals living with AIDS in the USA and Puerto et al. 2012); thus, we must continue to explore factors that Rico, age was negatively associated with self-judgment and cultivate recovery and resilience among child maltreatment positively associated with self-kindness (Eller et al. 2014). survivors. Although fear of self-compassion is associated with Studies of adolescents also indicate that age and gender are child maltreatment, we cannot assume that all survivors of differentially associated with self-compassion and depression. child maltreatment will report difficulties described here. Older adolescent females report the lowest levels of self- Continued research exploring child maltreatment and other compassion compared with younger adolescents and all males forms of interpersonal trauma is critical to expanding our un- (Bluth et al. 2017). Continued studies, on all individuals, are derstanding of self-compassion and potential unique implica- needed to clarify the patterns found here. The interaction of tions for traumatized populations. race, age, and gender may be particularly important to examine. A recent report from a nationally representative sample of Acknowledgments Terri Messman-Moore would like to acknowledge over 600,000 adolescents and adults in the USA suggests a general professional support for this and all scholarly activities from an endowed professor position, The O’Toole, Family Professor, at Miami significant and steady rise in mood disorder and suicide- University. related outcomes (suicidal ideation, plans, attempts, and deaths by suicide) among White, upper-middle class, Author Contributions Terri Messman-Moore and Prachi Bhuptani jointly college-aged women (Twenge et al. 2019). designed the study. Prachi Bhuptani conducted data analyses and wrote We utilized a retrospective questionnaire to assess child part of the results. Terri Messman-Moore wrote the introduction, methods, part of the results, and the discussion. All authors approved maltreatment that may be susceptible to memory bias, mini- the final version of the manuscript for submission. mization, or poor recall. Although the CTQ includes a minimization and denial subscale, we did not compute such scores, Compliance with Ethical Standards consistent with earlier studies that utilized the same measure (Boykin et al. 2018; Miron et al. 2014, 2016; Tanaka et al. Conflict of Interest The authors declare that they have no conflict of 2011; Vettese et al. 2011;Wuetal.2018). There is evidence interest. the CTQ may underestimate the incidence and impact of child maltreatment when minimization is not taken into account Ethical Approval All procedures were approved by the Committee for Use of Human Subjects in Research at Miami University. All procedures (MacDonald et al. 2016). However, another study of the performed in studies involving human participants were in accordance CTQ found few individuals minimized responses on the with the ethical standards of the institutional research committee at Miami CTQ, but those with high minimization/denial scores were University and with the 1964 Helsinki declaration and its later amend- unlikely to completely deny histories of abuse (Schmidt ments or comparable ethical standards. et al. 2018). Therefore, the pattern of findings reported here Informed Consent Informed consent was obtained from all individual may be a more conservative estimate of the true association participants in the study. between child maltreatment and self-compassion. The CTQ may identify milder cases of sexual abuse or actual non- abusive experiences. In one study, comparison with a behav- References iorally specific computerized interview showed significant agreement, but higher rates of sexual abuse on the CTQ Beckstead, J. W. (2012). 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