Guilt, Distress and Ways of Coping with Guilty Thoughts in a Clinical Sample A thesis submitted to the University of Manchester for the degree of Doctor of Clinical Psychology (ClinPsyD) in the Faculty of Medical and Human Sciences 2013 Lauren Pugh School of Psychological Sciences Division of Clinical Psychology Table of Contents List of Tables…………………………………………………………………………6 List of Figures………………………………………………………………………..7 Word Count…………………………………………………………………………..8 Abstract of Thesis…………………………………….………………………………9 Declaration………………………………………………………………………….10 Copyright Statement………………………………………………………………...11 Acknowledgements…………………………………………………………………13 Paper 1: Literature Review……………………………………………………….14 Preface………………………………………………………………………………15 Abstract……………………………………………………………………………..16 Introduction…………………………………………………………………………18 Method………………………………………………………………………………25 Search strategy……………………………………………………………....25 Inclusion and exclusion criteria……………………………………………..26 Results………………………………………………………………………………33 Overview of reviewed studies………………………………………………36 Is guilt related to PTSD symptomology?…………………………………...36 Model 1: Is guilt a causal process driving PTSD symptomology?…………41 Model 2: Is PTSD a causal process driving guilt?………………………….42 Model 3: Are guilt and PTSD symptomology causally unrelated despite their co-occurrence?………………………………………………………………43 Model 4: Do confounding variables explain the relationship between guilt and PTSD symptomology?………………………………………………….44 Summary of methodological considerations………………………………..47 Discussion…………………………………………………………………………..51 2 Implications for future research…………………………………………….53 Implications for clinical practice……………………………………………57 Conclusion…………………………………………………………………..59 References…………………………………………………………………………..60 Part 2: Empirical Study…………………………………………………………...70 Preface………………………………………………………………………………71 Abstract……………………………………………………………………………..72 Introduction…………………………………………………………………………74 Method………………………………………………………………………………80 Participants………………………………………………………………….80 Design……………………………………………………………………….80 Measures…………………………………………………………………….80 Procedure……………………………………………………………………84 Data analysis………………………………………………………………..84 Results………………………………………………………………………………86 Preliminary analysis………………………………………………………...86 Reliability of the GLAMS…………………………………………………..87 Concurrent validity of the GLAMS…………………………………………88 Construct validity of the GLAMS…………………………………………..90 Post-hoc analysis……………………………………………………………92 Discussion…………………………………………………………………………..95 Study limitations and future considerations……………………………….100 Clinical implications……………………………………………………….102 Conclusion…………………………………………………………………103 References…………………………………………………………………………105 3 Paper 3: Critical Appraisal………………………………………………………111 Overview…………………………………………………………………………..112 Aims of the research……………………………………………………….112 Rationale for Literature Review and Empirical Study…………………………….113 Reflections on Review and Research Process……………………………………..116 Methodological and Ethical Considerations……………………………………….123 Study design……………………………………………………………….123 Measures…………………………………………………………………...124 Recruitment and procedure………………………………………………..128 Sample……………………………………………………………………..130 Ethical issues………………………………………………………………131 Data analysis………………………………………………………………133 Implications for Future Research and Clinical Practice…………………………..136 References…………………………………………………………………………139 Appendix A: Clinical Psychology Review Author Guidance………………….….146 Appendix B: References for PTSD and Guilt Measures Cited (Not Discussed in Review)……………………………………………………………………………156 Appendix C: Psychological Assessment Author Guidance……………………….158 Appendix D: Study Poster…………………………………………………………166 Appendix E: Eligibility Criteria Form…………………………………………….167 Appendix F: GLAMS……………………………………………………………...168 Appendix G: Content Validity Evaluation Form………………………………….173 Appendix H: Face Validity Evaluation Form……………………………………..177 Appendix I: GI (State Guilt)……..………………………………………………..180 Appendix J: CORE-10 ……………………………………………………………181 4 Appendix K: BriefCOPE………………………………………………………….182 Appendix L: TCQ…………………………………………………………………184 Appendix M: Demographic Form.………………………………………………..186 Appendix N: Participant Information Sheet………………………………………187 Appendix O: Consent Form……………………………………………………….190 Appendix P: Follow-up Covering Letter………………………………………….191 Appendix Q: Research Ethics Committee Approval Letter……………………....192 5 List of Tables Paper 1: Literature Review Table 1: Study characteristics and findings…………………………………………28 Paper 2: Empirical Study Table 1: Frequency data for sample demographics…………………………………86 Table 2: Descriptive statistics for scales and subscales…………..…………………87 Table 3: Correlations between GLAMS Guilt Management subscales and BriefCOPE, TCQ, GI and CORE-10……………….……………………………….91 Table 4: Inter-scale correlations between GLAMS subscales……………………...92 Table 5: Model summary of regression coefficients of GLAMS subscales on distress at follow-up……...………………...………………………………………………..94 6 List of Figures Paper 1: Literature Review Figure 1: Four contrasting conceptualisations of the association between guilt and PTSD symptomology………………………………………………….….24 Figure 2: A flow chart outlining the article identification and selection process…..26 7 Word Count Thesis section Text (including References, Total abstract, tables & preface, figures) overview Thesis abstract 456 - 456 Paper 1 (Literature Review) 11,277 3,358 14,635 Paper 2 (Empirical Study) 7,972 2,066 10,038 Paper 3 (Critical Appraisal) 7,260 2,314 9,574 Total 26,965 7,738 34,703* *Excluding Appendices 8 The University of Manchester Guilt, Distress and Ways of Coping with Guilty Thoughts in a Clinical Sample Lauren Pugh Doctor of Clinical Psychology (ClinPsyD) 2013 Abstract of Thesis This thesis explores the role of guilt in post-traumatic stress disorder (PTSD) and ways of coping with guilt-related thoughts in a clinical sample. The thesis is presented as three papers that include a review of the literature, an empirical research study and critical appraisal of the research process. In the first paper, the author provides a systematic review of 27 studies to determine whether an association exists between guilt and symptoms of post-traumatic stress. Guilt remains an associated feature of PTSD; however, how these two constructs might be linked is not fully understood. Therefore the current review further evaluated the evidence for four competing models conceptualising the guilt-PTSD relationship. Overall, trauma-related guilt was positively related to PTSD symptomology even when controlling for depression. Guilt cognitions reflecting self-blame, perceived responsibility and wrongdoing were frequently associated with PTSD symptoms. Few studies found guilt was no longer related to PTSD symptomology when controlling for shame. Future studies ought to control for overlapping or confounding variables and further explore factors that may mediate the guilt-PTSD relationship such as coping. The second paper provided preliminary validation of a newly developed and unique measure of coping with guilty thoughts (GLAMS) in a clinical sample. A total of 67 participants from primary care services completed the GLAMS and measures of distress, guilt, coping and thought control. Eighteen completed the GLAMS and distress measure two weeks later. Overall the GLAMS evidenced moderate to high internal consistency and acceptable to good concurrent validity. Maladaptive subscales were found to be reliable over time. Higher self-punishment was related to greater guilt and distress and more mindful coping was related to a reduction in guilt supporting construct validity. Future research is required to test the stability of the GLAMS factor structure in a larger clinical sample. The GLAMS may have clinical utility in guiding psychological intervention towards more adaptive ways of coping with guilt. It may also provide a suitable outcome measure by monitoring the frequency in which clients engage in maladaptive ways of coping. The final paper provided a critical evaluation and reflection on the research process. Particular reference was made to the research rationale, methodological and ethical issues and considerations were given for future research and clinical practice. Conclusions drawn from this thesis are limited largely by the cross-sectional nature of most of the studies reviewed in paper 1 and insufficient numbers for the empirical study, which due to methodological and service-related constraints, limited further exploration of the data. Factor analysis and subsequent validation of the GLAMS in a larger sample is required to further support inferences drawn. 9 Declaration No portion of the work referred to in this thesis has been submitted in support of an application for another degree or qualification of this or any other university or other institute of learning. 10 Copyright Statement i. The author of this thesis (including any appendices and/or schedules to this thesis) owns certain copyright or related rights in it (the “Copyright”) and s/he has given The University of Manchester certain rights to use such Copyright, including for administrative purposes. ii. Copies of this thesis, either in full or in extracts and whether in hard or electronic copy, may be made only in accordance with the Copyright, Designs and Patents Act 1988 (as amended) and regulations issued under it or, where appropriate, in accordance with licensing agreements which the University has from time to time. This page must form part of any such copies made. iii. The ownership of certain Copyright, patents,