Header: COGNITIONS AND AFTER ELEVATION

Changes in Trauma-Related Cognitions and Emotions After Eliciting Moral Elevation:

Examining the Effects of Viewing Others’ Virtuous Behavior on Veterans with PTSD

Adam P. McGuire1*,2,3, Joanna Fagan3, Binh An N. Howard1,2, Annika Wurm3, & Yvette Z.

Szabo1,2,4

1 VISN 17 Center of Excellence for Research on Returning War Veterans, Waco, TX, USA

2 Central Texas Veterans Health Care System, Temple, TX, USA

3 Department of and Counseling, The University of Texas at Tyler, Tyler, TX, USA

4 Department of Health, Human Performance and Recreation, Baylor University, Waco, TX,

USA

*Preprint: This manuscript has not been peer reviewed.

Author Note

*Corresponding Author: Adam P. McGuire, PhD; VISN 17 Center of Excellence for

Research on Returning War Veterans, 4800 Memorial Dr. (151C), Waco, TX 76711;

Telephone: 254-297-5094; Email: [email protected] COGNITIONS AND EMOTIONS AFTER ELEVATION

Acknowledgment

The views expressed herein are those of the authors and do not necessarily reflect the official policy or position of the Department of Veterans Affairs or the United States Government.

Funding statement

This material is the result of work with resources and the use of facilities at the VISN 17 Center of Excellence for Research on Returning War Veterans and the Central Texas Veterans Health

Care System. Dr. McGuire is supported by a Small Projects in Rehabilitation Research Award

I21-RX003035 and Dr. Szabo is supported by Career Development Award IK1-RX003122 from the United States (U.S.) Department of Veterans Affairs, Rehabilitation Research and

Development Service.

Conflict of interest statement

The authors report no potential conflict of interest.

Contribution statement

AM, BAH, and YS collected data. AM analyzed the data with statistical consultation from YS.

AM, JF, BAH, AW, and YS drafted the manuscript. BAH, JF, and AW provided material support, and BAH provided administrative and technical support. All authors provided critical revision of the manuscript for important intellectual content. All authors read, discussed, and approved the final manuscript. COGNITIONS AND EMOTIONS AFTER ELEVATION

Abstract

Moral elevation is described as feeling inspired after witnessing someone perform a virtuous act.

Past work suggests moral elevation may be antithetical to PTSD, yet few studies have directly tested its impact on relevant symptoms. This experimental study assessed changes in trauma- related cognitions and emotions from after a trauma reminder task to after an elevation induction exercise. We hypothesized that higher elevation after the induction exercise would be associated with greater reductions in cognitions and emotions. Veterans with probable PTSD (N=64) completed measures of trauma-related cognitions and emotions, once after a written trauma narrative exercise (T1) and again after watching two videos designed to elicit elevation (T2).

Veterans also completed measures of state elevation after each video. Results suggest veterans experienced small significant decreases in self-blame, medium significant decreases in guilt, shame, and negative beliefs about others, and large significant decreases in negative beliefs about self between T1 and T2. As hypothesized, higher elevation predicted significantly greater reductions in all outcomes except self-blame, with a large effect for views of self and medium effects for guilt, shame, and views of others. These findings suggest elevation may be well-suited to target trauma-related symptoms and future research should examine its clinical utility.

Keywords: experimental design, veterans, guilt, shame, posttraumatic cognitions, positive COGNITIONS AND EMOTIONS AFTER ELEVATION

Changes in Trauma-Related Cognitions and Emotions After Eliciting Moral Elevation:

Examining the Effects of Viewing Others’ Virtuous Behavior on Veterans with PTSD

For United States veterans, posttraumatic stress disorder (PTSD) is a common consequence following exposure to a traumatic event that is associated with distress, impaired functioning and increased healthcare utilization (Calhoun et al., 2002; Chan et al., 2009; Lang et al., 2016). Symptoms of PTSD can involve distressing memories, dissociation, strong negative beliefs, avoidance behaviors, higher reactivity, and feelings of anger, guilt, or shame (American

Psychiatric Association, 2013). Compared to civilians, servicemembers are disproportionately diagnosed with PTSD (Hoge et al., 2004). Furthermore, veterans often experience severe symptomology and poor prognoses (Trivedi et al., 2015), highlighting the need to study and identify new avenues to enhance treatment. The purpose of this experimental study is to examine the role of moral elevation, a construct, in the context of experiencing trauma-related cognitions and emotions among a sample of veterans with PTSD symptoms.

Moral Elevation

Moral elevation (hereafter, elevation) is a multi-faceted social and emotional state that typically arises after observing another person engage in virtuous behavior (Haidt, 2003), such as an act of generosity, , or perseverance. In response, people often report subjective experiences of feeling uplifted, moved, or touched, along with physiological reactions such as a lump in one’s throat, piloerection (i.e., goosebumps), tears, or warmth in the chest; subsequently, the observer may also feel motivated or inspired to imitate the virtuous behavior they witnessed

(Algoe & Haidt, 2009; Silvers & Haidt, 2008).

Previous studies have identified a wide range of benefits and correlates of elevation. For example, in nonclinical populations, elevation was found to be associated with volunteerism and community engagement (Cox, 2010). It has also been correlated with increased prosocial COGNITIONS AND EMOTIONS AFTER ELEVATION behavior (Schnall et al., 2010) both in the context of considering one’s own moral self-image

(i.e., helping after affirming positive views of self; Schnall & Roper, 2012) and for extrinsic, altruistic purposes (i.e., helping others without expectation of reward; Van de Vyver & Abrams,

2015). Additionally, elevation experiences are correlated with increased positive affect, compassionate motives, and affiliation with others (Erickson et al., 2018). Notably, these studies also demonstrate the ability to induce elevation by asking participants to watch videos of real people demonstrating virtuous behavior—a common method in elevation research (Algoe &

Haidt, 2009; Erickson et al., 2018; Van de Vyver & Abrams, 2015). Thus, previous research suggests elevation has the capacity to affect emotional states, as well as motivations and behaviors associated with social engagement by means of compassion, prosociality, or social connection more broadly. However, it should be noted that many of these studies used community or university samples and the effects of elevation on military and clinical populations are less understood.

Elevation and PTSD

Despite limited research on clinical populations, there is some initial support for the notion that elevation could benefit psychological distress. Specifically, preliminary findings regarding elevation and trauma distress suggests elevation may be particularly well-suited to target the cognitive and emotional symptomatology of PTSD. Boosting moral elevation to target trauma distress warrants further investigation because it has been argued that elevation and its features are antithetical to PTSD symptoms (McGuire et al., 2019). For example, military-related trauma often corresponds with exaggerated negative cognitions about the world (Horwitz et al.,

2018), and sometimes moral injury—witnessing or perpetrating an act that violates deeply held morals or beliefs and results in significant psychological, behavioral, and spiritual consequences

(Litz et al., 2009). In contrast, elevation is associated with positive appraisal of others after COGNITIONS AND EMOTIONS AFTER ELEVATION witnessing and perceiving virtuous acts. People suffering from PTSD may experience strong negative emotions or sometimes a numbing of positive emotions (Able & Benedek, 2019), whereas elevation is described as a strong positive emotional response that can also include involuntary physiological reactions (e.g., lump in throat, piloerection, etc.). Finally, individuals with PTSD often engage in strong avoidance and isolation behaviors, retreating from the world and those around them (Badour et al., 2012; Sherman et al., 2016), whereas elevation may elicit the desire to help and connect with others and behave compassionately.

To date, only a few studies have empirically examined the theorized benefits of elevation in the context of trauma-related distress. Tingey et al. (2019) first demonstrated the relevance of elevation with a subclinical sample, finding that elevation was a predictor of posttraumatic growth and healthy adaptation following a college campus shooting. Expanding to a clinical population of veterans with PTSD, McGuire et al. (2019) examined veterans who were enrolled in residential trauma treatment. In this pilot study, weekly measures of elevation in response to the acts of fellow group members was associated with greater weekly engagement in the group treatment and lower avoidance symptoms at post-treatment. Notably, results from the initial phase (Phase 1) of the current experimental study demonstrated that veterans who reported elevated levels of PTSD symptoms can indeed experience elevation in response to portrayals of virtuous behavior (McGuire & Mignogna, 2021). In this study, veterans reported higher elevation after they watched videos intended to induce elevation compared to a control group that was presented with videos intended to induce general positive affect and amusement.

Additionally, veterans in the elevation condition described other clinically-relevant outcomes in qualitative response including lessened trauma-related thoughts and emotions, feeling inspired, a desire to engage in prosocial behaviors, an urge to reach out to family members or connect with others, and a desire to be a better person. These early findings, combined with theoretical COGNITIONS AND EMOTIONS AFTER ELEVATION rationale, suggest that elevation might have the capacity to counteract trauma distress and PTSD symptoms; however, more research is needed to test this theory.

Changes in Trauma Cognitions and Emotions

Two specific symptoms of PTSD that could be influenced by elevation are trauma-related cognitions and emotions. As previously noted, negative cognitions and emotions are prominent features of PTSD that can cause significant distress (Dunmore et al., 1999; Hayes et al., 2012;

Holmes et al., 2005). Trauma-related cognitions can include negative beliefs about the self (e.g.,

“There is something wrong with me as a person”; Horwitz et al., 2018), others (e.g., “People can’t be trusted”; Wells et al., 2019), or the world in general (e.g., “Nowhere is safe”; Brown et al., 2019). Two negative emotions that are prevalent among those with PTSD symptoms are guilt and shame. Guilt is considered a self-conscious moral emotion associated with feelings of remorse, and it can be a behavioral motivator to correct wrongs or return to a way of life more consistent with one’s moral code (Lee et al., 2001). Shame is also a negative moral emotion but is distinct from guilt based on slightly different cognitions and outcomes; shame-based thoughts typically entail feelings of inadequacy, being damaged, or being flawed. Unlike guilt, shame is linked with acts of aggression or social isolation (Crocker et al., 2016; Litz et al., 2009).

In addition to the need for reducing distress, these targets are also well-suited for examining the within-person effects of elevation because research suggests they can change and are not stable over time. For example, a longitudinal study of Israeli combat veterans and ex- prisoners of war found that cognitions, specifically those pertaining to the benevolence and safety of the world, can worsen over time. Other experimental studies have replicated these findings with regard to worsening cognitions and emotions using script-driven imagery activities and other such trauma reminders (Norte et al., 2013; Raudales et al., 2019). Conversely, studies have also found that the severity of trauma-related cognitions and emotions can lessen over time COGNITIONS AND EMOTIONS AFTER ELEVATION in the context of experimental studies (Hagenaars & Arntz, 2012) and during the course of treatment (Macdonald et al., 2016; Peck et al., 2018). Given the capacity for cognitions and emotions to change—an innate goal of trauma-focused treatment for PTSD—the clinical utility of eliciting elevation could be demonstrated by assessing for within-person changes in trauma cognitions and emotions following an elevation induction exercise. This would expand our understanding of elevation’s potential to impact survivors of trauma and people suffering from

PTSD symptoms, while also adding to the literature by identifying a novel tool to alleviate cognitive and emotional distress in this population.

Current Study

The purpose of this study is to investigate the specific effects of eliciting elevation in veterans with significant PTSD symptoms on trauma-related cognitions and emotions following a trauma reminder—expanding on preliminary findings from the initial phase of this experiment that demonstrated veterans with PTSD symptoms have the capacity to experience elevation.

Based on existing research, it was hypothesized that negative emotions (shame and guilt) and negative cognitions about the self, others, and self-blame would reduce over time following a written trauma narrative exercise. We also hypothesized that higher levels of elevation following exposure to elevation-inducing videos would predict greater decreases in negative emotions and cognitions from post-trauma narrative to post-elevation induction.

Method

Participants and Procedures

Recruitment methods included mailing out recruitment letters, in-person recruitment in

PTSD clinics, flyers, and direct referrals from Veterans Health Administration clinicians. First, veterans were screened for potential eligibility using the Posttraumatic Checklist for Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (PCL-5; Weathers et al., 2013). Veterans COGNITIONS AND EMOTIONS AFTER ELEVATION with a total score of 32 or higher were viewed as experiencing significant symptoms of PTSD and therefore, deemed eligible to participate in the study. Exclusion criteria were active psychosis, active mania/hypomania, cognitive disorders (e.g., dementia, traumatic brain injury), and age of 90 years or older. Eligibility was assessed during a phone screen. Following the phone screen, eligible veterans scheduled an in-person appointment and provided written consent to participate in the study upon arrival to that appointment. All study procedures were approved by the local Institutional Review Board.

This study included two phases or versions of an experimental session with slight differences between Phase 1 and 2. Veterans who participated in Phase 1 first completed baseline measures, then completed a written trauma narrative describing their worst traumatic event in detail for 15 minutes, followed by questionnaires that assessed the severity of trauma-related cognitions and emotions experienced at that moment (Time 1; T1). All participants were then presented with three video clips, followed by brief measures to assess state-level emotional responses to each video. The first video was intended to be a neutral stimulus that did not elicit positive or negative emotions, which served as quality control in previous analyses. Next, participants were randomized to view either two elevation videos or two amusement videos that were intended to elicit the target emotion. Both sets of videos lasted approximately 7 minutes in total. After watching both videos, participants were asked to complete a brief journal exercise describing their reactions to the video with prompts (see Supplemental Materials). After the journal exercise, they completed the same trauma-related cognition and emotion questionnaires for a second time (Time 2: T2). The two assessments of cognitions and emotions were administered approximately 50 minutes apart.

The experimental session for Phase 2 was nearly identical to Phase 1 with a few exceptions. First, there was no randomization in Phase 2 such that all participants were presented COGNITIONS AND EMOTIONS AFTER ELEVATION with elevation videos (the same videos as Phase 1). This decision was based on results quantitative and qualitative analyses of Phase 1 data that indicated the elevation videos elicited a distinct response from positive affect or general amusement that was consistent with the theory of elevation (McGuire & Mignogna, 2021). Second, we expanded our investigation to include saliva sample collection at four timepoints for future analysis of biomarkers associated with elevation.1 The schedule for session procedures across both phrases is presented in Figure 1.

t s o e AMUSED CONDITION n s

y t

l Experiment Task u a Video Clip: Amusement 1 b Y n

, E

a Self-Report Measure

d K

n State Measures e i z

i Not Included in Analyses d m e o d Video Clip: Amusement 2 d u l n c a n

i State Measures R

Eligibility Trauma Narrative ELEVATION CONDITION Journal Response Baseline Measures Screen Exercise (15 min) Exercise (10 min) I Video Clip: Elevation 1 Demographic & Trait PCL > 32 e T1 Measures: T2 Measures:

s State Measures

a Cognition & Emotion Cognition & Emotion h

P Video Clip: Elevation 2 State Measures

Saliva Saliva Saliva Saliva Sample 1 Sample 2 Sample 3 Sample 4 2

e Eligibility Trauma Narrative Video Clip: Elevation 1 Journal Response

s Baseline Measures (18 min)

a Screen Exercise (15 min) Exercise (10 min) Demographic & Trait State Measures h PCL > 32

P T1 Measures: T2 Measures: Cognition & Emotion Video Clip: Elevation 2 Cognition & Emotion State Measures

Figure 1. Procedures for experimental sessions as administered in Phase 1 and Phase 2.

To address our stated aims, we combined the samples from Phase 1 and 2. Because Phase

1 randomized all participants to either an amusement or elevation condition, and proposed analyses for this paper aim to assess the impact of elevation specifically, we excluded all participants who were randomized to the amusement condition. For Phase 1, 24 participants were randomized to the elevation condition, and therefore, included in analyses. For Phase 2, 46

1 Additionally, participants in Phase 2 were presented with slightly different measures that were added for secondary analyses and not reported here. A list of all measures and administration schedule can be found in the Supplemental Materials. COGNITIONS AND EMOTIONS AFTER ELEVATION participants were enrolled, but five participants were excluded because they did not complete the experimental session. One additional participant was removed because study staff noted significant issues with inattention throughout the session (e.g., sleeping during videos). The final sample from Phase 2 included 40 participants, with a total sample size across the two phases of

64.

Measures

PTSD Symptoms

The 20-item PCL-5 (Weathers et al., 2013) assessed the severity of PTSD symptoms over the past month. Items were rated on a Likert-style scale from 1 (not at all) to 5 (extremely). Total scores are calculated by summing all items with higher scores indicating greater symptom severity. In this sample, person mean imputation was used to create total scores because one participant had one missing item. The PCL-5 has demonstrated adequate reliability and validity in previous studies that included veteran samples, with evidence that scores of 32 or higher indicate subclinical or clinical PTSD severity (Bovin et al., 2016; Wortmann et al., 2016).

Internal consistency in the present sample was a = .86 [95% CI: .82, .91].

State Elevation

Currently, there are no standardized measures for assessing state-level elevation. The

Elevation Scale (ES; Landis et al., 2009) or a modified version of it is widely used, but this scale assesses trait-like tendencies to experience elevation rather than a momentary state response. To capture state elevation in this study (i.e., response to elevation stimuli), we combined items adapted from the ES with items from a daily elevation measure previously used with a clinical population (Erickson & Abelson, 2012). Instructions from the ES were altered by asking participants to rate the extent they experienced 12 items immediately after watching video stimuli on a scale from 0 (not at all) to 4 (extremely). All items were summed to create a total COGNITIONS AND EMOTIONS AFTER ELEVATION score using person mean imputation because one participant had one missing item. Higher scores indicated greater elevation. Internal consistency in the present sample was a = .93 [.91, .96] for state elevation following Video 1 and a = .95 [.93, .97] for state elevation following Video 2.

Pre-Post Measures

Shame and Guilt. The 10-item State Shame and Guilt Scale (SSGS; Marschall et al.,

1994) assessed severity of state-level shame and guilt at T1 and T2. Items were rated on a scale from 1 (I do not feel this was at all) to 5 (I feel this way very strongly) and summed to create total scores, with higher scores indicating more severe shame and guilt. Internal consistency for state shame was a = .88 [.83, .93] at T1 and a = .86 [.81, .92] at T2; state guilt was a = .88

[.84, .93] at T1 and a = .85 [.79, .91] at T2.

Negative Trauma-Related Cognitions. The 36-item Posttraumatic Cognition Inventory

(PTCI; Foa et al., 1999) assessed strength of negative cognitions and beliefs associated with an index trauma—in this case, the index trauma referred to the trauma described in the written narrative exercise. Each item is rated from 1 (totally disagree) to 7 (totally agree).

Administration for this study was modified by instructing veterans to rate the extent to which they endorsed each item “at this moment.” The PTCI was administered twice: at T1 and T2.

Scores on each item are summed to create subscale scores for negative views of the self, the world or others, and self-blame, with higher scores indicating stronger beliefs. Person mean imputation was used for calculating subscale scores given that two participants had two missing items. Previous studies demonstrated reliability and validity for all three subscales (Sexton et al.,

2018). This study also found adequate reliability for each subscale: PTCI negative view of self was a = .95 [.93, .97] at T1 and a = .96 [.94, .97] at T2; PTCI negative view of others was a = .80 [.72, .88] at T1 and a = .89 [.85, .93] at T2; PTCI self-blame was a = .83 [.76, .90] at T1 and a = .86 [.81, .92] at T2. COGNITIONS AND EMOTIONS AFTER ELEVATION

Data Analytic Plan

All data management and analyses were conducted with R (R Core Team, 2021). First, to test our hypothesis that emotions and cognitions reduced from T1 to T2, we used the base stats package to calculate paired samples t-tests and the rstatix package (Kassambara, 2021) to estimate standardized mean difference effect sizes with 95% confidence intervals (CI). We interpreted d > 0.20, d > 0.50, and d > 0.80 as small, medium, and large effects (Cohen, 1988).

To test our second hypothesis that higher elevation experienced after videos would be associated with greater reductions in cognition and emotion, we used a series of multiple linear regression models for five outcomes of interest: guilt, shame, negative views of self, self-blame, and negative views of others. Specifically, we fit a baseline model and a theoretical model for each outcome in which the T2 score of that cognition or emotion was set as the dependent variable. The baseline model included the T1 score of the same target variable such that remaining variance explained in the model could be attributed to residual change in that variable.

Additionally, the baseline model included phase (1 or 2) as a covariate to account for potential differences in responses across Phase 1 and Phase 2. The theoretical model added the average elevation score across both videos as a predictor in addition to the other two covariates. Thus, effects for average elevation as a predictor would demonstrate the extent to which elevation responses explained unique variance in the observed residual change or decrease for each outcome. Regression coefficients were reported in the standardized metric (b).

We also examined R2 to understand the percent of variance accounted for in the model and inspected f2 to assess effect size. To further examine the hypothesis that higher elevation is linked with greater reductions in trauma-related cognitions and emotions, we calculated changes in effect sizes (Df2) between the baseline model and the theoretical model after average state elevation was added as a predictor. We interpreted changes in f2 > 0.02, f2 > 0.15, and f2 > 0.35 as COGNITIONS AND EMOTIONS AFTER ELEVATION small, medium, and large effects (Cohen, 1988) attributable to the addition of state elevation. We also calculated 95% CI for change in f2 using online calculators (Soper, 2006).

Results

The final sample included 64 veterans (Mage = 54.38, SD = 12.88, 82.5% male) with

61.9% identifying as White, 25.4% as Black, 6.3% as American Indian or Alaskan native, and

6.4% as Other. Most veterans were in the Army (71.4%) followed by Marines (12.7%), and

Navy (12.7%) with 77.8% reporting combat exposure during their service. The means and standard deviations for all measures used in the subsequent analyses are reported in Table 1.

Table 1. Means and standard deviations for study variables. T1: Post-Trauma T2: Post-Elevation Variable Baseline Elevation Narrative Videos PCL-5 Total 58.68 (11.19) State Elevation - Video 1 20.75 (11.79) State Elevation - Video 2 22.41 (12.68) Average State Elevation 21.58 (11.81) State Shame 12.97 (5.92) 9.67 (4.37) State Guilt 14.48 (6.14) 11.43 (5.10) PTCI Neg Views of Self 83.24 (26.28) 70.21 (26.38) PTCI Self-Blame 16.04 (7.81) 14.73 (7.73) PTCI Neg Views of World 39.20 (6.62) 35.35 (8.57) Note. N = 64

Changes in Cognitions and Emotions

Consistent with hypotheses, participants reported medium significant decreases in state guilt and state shame from the moment they completed the trauma narrative exercise (T1) to after viewing both videos and completing the reflection exercise (T2; see Table 2). Regarding PTCs, consistent with hypotheses, participants reported medium significant decreases in negative COGNITIONS AND EMOTIONS AFTER ELEVATION beliefs about others from pre- to post-video, small significant decreases in self-blame, and large significant decreases in negative beliefs about self.

The Impact of Elevation on Changes in Cognitions and Emotions

As hypothesized, higher elevation following the two elevation-inducing videos was a significant predictor of residual change or decrease in state guilt (b = -0.24, SE = 0.08, p = .006) and state shame (b = -0.28, SE = 0.10, p = .005) from before and after the elevation videos.

Furthermore, adding elevation as a predictor of change resulted in a medium-sized contribution

2 2 to the model for both state guilt (Df = 0.33) and shame (Df = 0.23), with the theoretical model explaining 60% of the variance in guilt at T2 and 45% of the variance in shame at T2. See Table

3 for a summary of models.

Table 2. Comparing cognitions and emotions between post-trauma narrative and post-videos

Variable Mdiff t p d (95% CI) Guilt (SSGS) -3.18 5.92 <.001 0.76 [0.57, 1.00] Shame (SSGS) -3.43 5.65 <.001 0.72 [0.56, 0.93] Negative beliefs about self (PTCI) -13.47 6.27 <.001 0.80 [0.62, 1.04] Self-blame (PTCI) -1.37 3.15 .002 0.40 [0.14, 0.69] Negative beliefs about others/world (PTCI) -4.11 3.70 <.001 0.52 [0.31, 0.74] Note. N = 64; Based on Cohen (1988), d > 0.20, d > 0.50, and d > 0.80 are interpreted as small, medium, and large effects. SSGS = State Shame and Guilt Scale, PTCI = Posttraumatic Cognitions Inventory

As hypothesized, higher elevation was also a significant predictor of residual change or decrease in negative beliefs about self (b = -0.30, SE = 0.07, p < .001) and negative beliefs about others (b = -0.32, SE = 0.10, p = .003) from before and after the elevation videos. The addition of

2 elevation resulted in a large-sized contribution to the model for negative beliefs about self (Df =

0.75), with the theoretical model explaining 71% of the variance explained in negative views of self at T2. Furthermore, adding elevation as a predictor of change in negative beliefs about others COGNITIONS AND EMOTIONS AFTER ELEVATION

2 resulted in a medium-sized contribution to the model (Df = 0.25) with the theoretical model

explaining 44% of the variance in negative views of others at T2.

Table 3. Model comparison for baseline and theoretical models (IV = State Elevation Average; COV = T1 Score, Phase; DV = T2 Score) Residual change Baseline model F and R2 Elevation model F and R2 b (SE) Df2 95% CI

2 2 Guilt (SSGS) F(2, 58) = 34.06, p < .001, R = .54 F(3, 57) = 28.23, p < .001, R = .60 -0.24 (0.08)** 0.33 [0.08, 0.73]

2 2 Shame (SSGS) F(2, 58) = 17.02, p < .001, R = .37 F(3, 57) = 15.58, p < .001, R = .45 -0.28 (0.10)** 0.23 [0.02, 0.54]

Neg view of self 2 2 F(2, 59) = 51.11, p < .001, R = .63 F(3, 58) = 47.78, p < .001, R = .71 -0.30 (0.07)*** 0.75 [0.34, 1.51] (PTCI)

2 2 Self-blame (PTCI) F(2, 59) = 131.70, p < .001, R = .82 F(3, 58) = 86.33, p < .001, R = .82 -0.01 (0.06) 0.00 [0.00, 0.00]

Neg view of others 2 2 F(2, 59) = 15.83, p < .001, R = .35 F(3, 58) = 15.35, p < .001, R = .44 -0.32 (0.10)** 0.25 [0.03, 0.58] (PTCI) Note. **p < .01, ***p < .001; Based on Cohen (Cohen, 1988), f2 ≤ 0.02 was interpreted as a small effect; f2 ≤ .15 as a medium effect; and, f2 ≤ 0.35 as a large effect. SSGS = State Shame and Guilt Scale; PTCI = Posttraumatic Cognitions Inventory

However, contrary to hypothesis, higher elevation was not a significant predictor of

residual change for self-blame (b = -0.01, SE = 0.06, p = .885) and the addition of state elevation

2 did not contribute significant changes in the effect size of the model (Df = 0.00).

Discussion

Existing literature supports the notion that veterans with PTSD can experience elevation

and that doing so may elicit distinct responses from other positive emotions. The purpose of the

present study was to further evaluate the role of elevation on trauma-related cognitions and

emotions among a sample of veterans with probable PTSD. It was hypothesized that negative

emotions (shame and guilt) and negative cognitions about the self, others, and self-blame would

reduce from T1 to T2. We also hypothesized that higher levels of elevation reported following

exposure to elevation-inducing videos would predict greater decreases in negative emotions and

cognitions from post-trauma narrative to post-elevation induction.

Changes in Cognitions and Emotions COGNITIONS AND EMOTIONS AFTER ELEVATION

Consistent with hypotheses, there were significant differences in levels of negative emotions (i.e., shame and guilt) and negative cognitions about the self, others, and self-blame between T1 to T2; these reduced from after a written trauma narrative exercise to after watching elevating videos. Pre-post mean difference scores ranged in magnitude from small to large, with the largest difference found in participants’ negative views about the self, followed by negative beliefs about others, guilt, and shame. Self-blame had the smallest effect relative to other changes, which could suggest that guilt, shame, and the other types of trauma cognitions may be particularly amenable to change following exposure to elevation stimuli, whereas self-blame may be less flexible or more resistant to change. One possible explanation for the smaller effect is potential heterogenous experiences of self-blame. For example, Janoff-Bulman (1979) proposed two types of self-blame attributions: behavioral and characterological self-blame. Behavioral self-blame reflects survivors’ belief that their own behavior led to the event/assault.

Characterological self-blame focuses not on behavior but on the survivor’s personality or character as the cause of event. Perhaps it is difficult to modify specific self-blame attributions, which could be made even more rigid depending on the type of traumatic event (e.g., behavioral self-blame for engaging in combat). More research is needed to understand how variations of self-blame and the context of traumatic events influences changes in beliefs about self-blame, particularly to the extent it informs existing and future treatment application.

Effects of Elevation on Changes in Cognitions and Emotions

Subsequent analyses were used to expand on these findings and assess the extent to which reported levels of elevation predicted changes in each cognition and emotion. As hypothesized, higher state elevation experienced after viewing inspirational videos was a significant predictor of reductions in guilt, shame, negative views of self, and negative views of others. Regarding significant findings, there was a medium effect on changes in guilt, shame, and COGNITIONS AND EMOTIONS AFTER ELEVATION negative views of others, whereas we found a large effect for negative views of the self.

Although we did not directly test mechanisms for these associations, there are several potential explanations based on the existing literature for these outcome variables.

Guilt is an affective state signifying the psychological consequences of violating moral standards (Kugler & Jones, 1992). Guilt can arise following a specific action or failure to act, and thus result in experiencing remorse or regret, which could also be linked with a desire for reparations (Tangney et al., 1992). Conversely, research suggests elevation can motivate an affiliative action tendency to help others, emulate , and become a better person (Algoe &

Haidt, 2009; Haidt, 2003). Perhaps experiencing the urge or action tendency following elevation reduces guilt by providing an awareness of opportunities to engage in reparative behavior. With shame, the focus of concern is the self; negative experiences are a reflection of the bad self and the self is consequently scrutinized and negatively evaluated (Tangney et al., 1992). Given that elevation is theorized to shift attention outside the self (Keltner & Haidt, 2003), it may impact levels of shame by redirecting one’s focus from negative self-perceptions to the uncommon acts of goodness or moral beauty of others. Shame is characterized by heightened self-focus, whereas elevation is an other-praising emotion that draws attention toward the good in others (Algoe &

Haidt, 2009; Erickson et al., 2018).

Because elevation involves positive appraisals of others’ actions by definition, it follows that there would be a significant effect on changes in negative cognitions about the world.

Specifically, negative cognitions about the world involve beliefs that people cannot be trusted and that the world is a dangerous place (Foa et al., 1999), whereas experiences of elevation are associated with connectedness, openness, and loving feelings towards other people (e.g., Landis et al., 2009). Perhaps elevation provides an opportunity to collect evidence that might contradict strong negative beliefs about others, while also providing exposure to experiencing genuine COGNITIONS AND EMOTIONS AFTER ELEVATION compassion towards strangers or humanity in general. These findings are consistent with another study that examined daily elevation in a clinical population of people with depression and anxiety, which suggested higher levels of elevation were linked to stronger beliefs that people should look out for one another, perceived closeness to others, and urges to support and help people (Erickson & Abelson, 2012).

Although elevation is an other-praising emotion, it was also associated with a large magnitude change in negative views of the self. Notably, this was a stronger effect relative to medium changes in negative views of others. One potential explanation for this finding is that elevation might increase awareness of one’s capacity for good or moral characteristics in general.

Monin (2007) proposed that observing exceptional moral behavior may trigger an upward social comparison, which might remind people of their own values and elicit evidence or recognition that one is capable of acting in line with those values (e.g., being a good, moral person; Sherman

& Cohen, 2006). A study by Schnall and Roper (2012) also found that self-affirmation (before an elevating film clip) was associated with participants’ identifying positive qualities within themselves (e.g., helping others) and accessing evidence of their own ability to do good. Last, previous studies have found that elevation is associated with a strong desire to become a better person (e.g., Siegel et al., 2014); perhaps experiencing the motivation for self-improvement alone has some kind of positive impact on views of the self. Now that the present study provides initial evidence that elevation is associated with cognitive and emotional changes, future research is needed to expand on these findings and decipher the specific mechanisms that facilitate the change process.

Contrary to hypotheses, state elevation was not a significant predictor of changes in self- blame. There are several possible reasons this association was not observed in the present study.

First, it could be attributed to the small effect for reduced self-blame, which may indicate there COGNITIONS AND EMOTIONS AFTER ELEVATION was not enough variance or change in reported self-blame for state elevation to be a meaningful predictor. Alternatively, conceptual differences between self-blame and the other outcomes may be differentially influenced by elevation. Conceptually, self-blame may be tied to specific facts surrounding certain events/trauma that might be more descriptive of the traumatic incident itself

(Startup et al., 2007) and less flexible to interpretation (i.e., I did not fight-off my attacker).

Alternatively, guilt, shame, and negative cognitions of the self/world could be described as more generalized and somewhat based on interpretations of the traumatic event; therefore, those generalized beliefs or interpretations may be more amenable to change than self-blame. For example, it seems possible that elevation may not impact self-blame if a veteran believes they had some degree of responsibility for an event (i.e., I had a role in a friend’s death during a combat situation), but one can reasonably assume it is possible to reduce the amount of guilt or shame that veteran experiences about that same event. Lastly, previous literature has indicated shared attributes between self-blame and negative view of the self (Startup et al., 2007), thus the

PTCI may not be a sufficient measurement for self-blame. Further research is needed to identify mechanisms exclusive to changes in self-blame and to determine whether features of this trauma- cognition type are in fact resistant to change following experiences of elevation.

Potential Treatment Implications

These findings have potential implications for the clinical utility of elevation and treatment for trauma distress. Perhaps increasing exposure to other’s virtuous behavior and inducing elevation could be incorporated into trauma treatment approaches, such as cognitive behavioral interventions, to target greater reductions in PTSD symptoms. In the short-term, elevation might be useful as a novel tool to regulate emotions and buffer against strong negative beliefs that veterans with PTSD likely encounter on a daily basis. For example, it might be helpful in response to distress associated with trauma reminders, similar to this study in which COGNITIONS AND EMOTIONS AFTER ELEVATION elevation induction occurred immediately after a trauma-cue reminder. In the long-term, repeated inductions could promote increased trait-level sensitivity to experiencing elevation—thus, resulting in greater awareness of the goodness in others and increased likelihood of feeling motivated to engage in behaviors consistent with trauma recovery (e.g., connect with others or prosociality). If elevation is to be used as a therapeutic tool, then additional research will be required to determine whether exposure to elevation leads to observable mechanisms as theorized (e.g., increased social engagement) and whether those mechanisms directly mediate decreased PTSD symptoms and increased well-being. Furthermore, implementation research is also needed to inform whether elevation induction and related activities can be used as a brief skill or intervention, a standalone intervention, or perhaps a supplement to other treatments for

PTSD.

Limitations

The findings of the present study should be considered in the light of study limitations. In this investigation, we used a sample size that was primarily male and white. Future studies should aim to expand our understanding of this phenomenon with more diverse samples. This study combined samples with two different procedures; while sensitivity analyses were conducted and study phase was not associated with outcomes, differences in procedures could have had some unforeseen effects on results. Because the authors are unaware of other studies examining elevation and trauma-related symptoms in an experimental study, it is unclear if these findings are specific to veterans or if they generalize to the civilian population, and subsequently a wider-range of trauma types. Given that there are no standardized measures for assessing state elevation to date, the elevation measure used for this study is limited and further psychometric analyses are needed. Without developing and testing a new measure, we aimed to address this limitation by utilizing an elevation measure that demonstrated adequate reliability in past studies COGNITIONS AND EMOTIONS AFTER ELEVATION

(Landis et al., 2009), is consistent with the established theoretical underpinnings of elevation, and demonstrated high internal consistency in the present study. Finally, the present study examined change in several outcomes following elevation stimuli alone without a control condition. This choice was based on Phase 1 findings that elevation responses were stronger and distinct following the elevation stimuli compared to amusement videos, which suggests the video stimuli used across both phases elicited the desired emotional response. However, the lack of a control group in the present study that examined changes in different outcomes precludes causal inference.

Conclusion

Findings from this study showed significant changes in negative emotions and cognitions about the self, others, and self-blame following a written trauma narrative and elevation-inducing videos. Greater experiences of elevation after watching elevation-inducing videos were associated with each facet, with the exception of self-blame. According to results, exposure to elevation videos may shift trauma-related cognitions and emotions among a sample of veterans with probable PTSD. Future studies should continue to explore this positive emotion and expand our understanding of the clinical utility of elevation. COGNITIONS AND EMOTIONS AFTER ELEVATION

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