Trauma appraisals, emotion regulation difficulties, and self-compassion predict posttraumatic stress symptoms following childhood abuse

Child Abuse & Neglect 65 (2017) 37–47

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Child Abuse & Neglect

Trauma appraisals, emotion regulation difficulties, and self-compassion predict posttraumatic stress symptoms following childhood abuse M. Rose Barlow a,∗ , Rachel E. Goldsmith Turow b,c , James Gerhart d a b c d

i4Health at Palo Alto University, 1791 Arastradero Rd., Palo Alto, CA 94304, USA Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA Seattle University, 901 12th Ave., Seattle, WA 98122, USA Rush University Medical Center, 1653 W. Congress Pkwy, Chicago, IL 60612, USA

a r t i c l e

i n f o

Article history: Received 31 August 2016 Received in revised form 4 January 2017 Accepted 5 January 2017 Keywords: Trauma Emotion regulation Appraisals Self-compassion PTSD symptoms

a b s t r a c t Experiencing traumatic events and abuse is unfortunately common in general, non-clinical samples. Recent research indicates that the ways in which individuals interpret traumatic experiences, as well as the ways that they manage challenging emotions in general, may statistically predict post-traumatic stress disorder (PTSD) symptoms to a greater extent than does trauma itself. Negative trauma appraisals, generalized emotion regulation (ER) difficulties, and low levels of self-compassion have each been shown to influence the connection between trauma exposure and subsequent PTSD symptoms. However, little is known regarding how these processes interact, or their relative contributions to mental health after trauma. The current study analyzed data from 466 university students who completed self-report measures of childhood abuse, PTSD symptoms, trauma appraisals, ER difficulties, and self-compassion. Childhood abuse exposure and PTSD symptoms were positively associated with negative trauma appraisals and ER difficulties, and negatively associated with self-compassion. Self-compassion was inversely associated with negative trauma appraisals and ER difficulties. Multiple mediation analyses demonstrated that negative trauma appraisals, ER difficulties, and levels of self-compassion fully explained the link between abuse exposure and PTSD symptoms via several specific pathways. These findings suggest that researchers, clinicians, and abuse survivors can benefit from addressing these interconnected domains during treatment and recovery processes. © 2017 Elsevier Ltd. All rights reserved.

Recent research indicates that the ways in which individuals interpret traumatic experiences, as well as the ways that they manage challenging emotions in general, may predict post-traumatic stress disorder (PTSD) symptoms to a greater extent than does the trauma itself. Trauma appraisals, such as shame and self-blame, appear to contribute to PTSD symptoms over and above the impact of trauma exposure (Cromer & Smyth, 2010; DePrince, Chu, & Pineda, 2011). Generalized difficulties with emotion regulation (ER), or people’s efforts and successes in managing distress, also influence the development and maintenance of PTSD symptoms after trauma (e.g., Badour & Feldner, 2013; Powers, Cross, Fani, & Bradley, 2015). In addition, self-compassion, or the tendency to meet one’s own internal struggles with kindness rather than criticism, seems to mitigate PTSD symptoms and to facilitate trauma recovery (Játiva & Cerezo, 2014; Zeller, Yuval, Nitzan-Assayag, & Bernstein, 2015). Despite recent advances showing that these internal cognitive and emotional processes are strongly linked with PTSD

∗ Corresponding author. E-mail addresses: [email protected] (M.R. Barlow), [email protected] (R.E. Goldsmith Turow), James [email protected] (J. Gerhart). http://dx.doi.org/10.1016/j.chiabu.2017.01.006 0145-2134/© 2017 Elsevier Ltd. All rights reserved.

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symptoms and recovery, there exists scant evidence examining interrelationships among these domains or evaluating their relative contributions to PTSD symptoms. Childhood abuse is prevalent, with estimates of child sexual abuse hovering around 22% prevalence in women and 9–10% in men (e.g., Bolen & Scannapieco, 1999; Hebert, Tourigny, Cyr, McDuff, & Joly, 2009). The vast majority of child sexual abuse is not disclosed to anyone while it is happening, if ever, and is rarely investigated by any protective agencies (Fontes & Plummer, 2010; Hebert et al., 2009). Childhood abuse of all kinds is even more prevalent, and is strongly associated with a range of physical and mental health difficulties; it is also strongly linked with negative trauma appraisals, ER difficulties, lower levels of self-compassion, and more PTSD symptoms (Choi, Choi, Gim, Park, & Park, 2014; Sundermann & DePrince, 2015). Childhood abuse may contribute to maladaptive cognitive and emotional tendencies through several pathways, including the common responses of internalizing abuse as deserved (Briere, 1992) and of forming insecure attachments to parents or caregivers, a feature linked with deficits in emotional coping skills (Alink, Cicchetti, Kim, & Rogosch, 2009). In addition, both negative trauma appraisals (such as shame) and ER difficulties appear to contribute to the perpetration of violence (Hundt & Holohan, 2012). On the bright side, interventions that decrease negative trauma appraisals, cultivate healthy ER skills, or promote self-compassion demonstrate meaningful reductions in PTSD symptoms and other forms of distress (e.g., Kearney et al., 2013; Schumm, Dickstein, Walter, Owens, & Chard, 2015). However, these domains have most commonly been measured separately, both as predictors of mental health problems and as roads to recovery. A richer understanding of the interrelationships between the internal factors that maintain distress in abuse survivors – and that may enhance abuse recovery – may advance intervention and treatment efforts. 1. Negative trauma appraisals Negative trauma appraisals are strongly linked with PTSD symptoms (Cromer & Smyth, 2010; DePrince et al., 2011). Trauma appraisals such as self-blame or shame can exacerbate and maintain PTSD symptoms (e.g., Uji, Shikai, Shono, & Kitamura, 2007). In fact, negative trauma appraisals predict symptoms of PTSD and depression over and above the extent of trauma exposure that individuals experience (Andrews, Brewin, Rose, & Kirk, 2000). Research demonstrates that appraisals about trauma both at the time of trauma and later in life are associated with a range of symptoms including PTSD, depression, and general distress (DePrince, Zurbriggen, Chu, & Smart, 2010). Encouragingly, trauma survivors can change their trauma appraisals and decrease related PTSD symptoms (Price, MacDonald, Adair, Koerner, & Monson, 2016). For instance, Schumm et al. (2015) analyzed data from 195 veterans with PTSD and tracked trauma-related thoughts and PTSD symptoms over time as the veterans participated in a therapy program. Changes in trauma-related thoughts such as self-blame and negative beliefs about oneself preceded decreases in veterans’ levels of PTSD and depression (Schumm et al., 2015). Similarly, McLean, Yeh, Rosenfield, and Foa (2015) demonstrated that changes in negative trauma-related cognitions led to reductions in PTSD and depression among 61 assault victims. These treatment studies complement other research evidence demonstrating that trauma appraisals may mediate the link between trauma exposure and PTSD (e.g., Meiser-Stedman, Dalgleish, Glucksman, Yule, & Smith, 2009). Negative trauma appraisals have been shown to impact PTSD symptoms among diverse samples, including military veterans (Schumm et al., 2015) and survivors of interpersonal violence (Beck et al., 2011). Childhood abuse may be especially likely to produce negative trauma appraisals, because it occurs concurrently with developmental processes related to cognitions about the self; because the abuse itself may include and inculcate appraisals such as self-blame; and because negative appraisals may arise as a way to resolve the cognitive dissonance that arises when being hurt by a caregiver (Briere, 1992). Examples of common negative appraisals include ideas like “I deserve what happened to me” and “I’m a bad person.” Survivors of childhood physical, sexual, and emotional abuse can have lingering shame, self-blame, mistrust, hostility, sense of inadequacy, and alienation throughout adulthood (Choi et al., 2014; Salmon et al., 2006). The experience of childhood abuse and/or subsequent negative trauma appraisals also appears to influence individuals’ responses to trauma in adulthood. For instance, a history of childhood abuse increased the likelihood of self-blame following intimate partner abuse among a sample of 230 adult women (Babcock & DePrince, 2012). These and other studies indicate that negative trauma appraisals may comprise an important mechanism in the onset, maintenance, and reduction of PTSD symptoms among both trauma survivors in general and among childhood abuse survivors in particular. 2. Emotion regulation Emotion regulation (ER) refers to the ways in which individuals influence, manage, experience, and express their responses to internal or external events (Gross, 1998). ER strategies may include methods shown to be beneficial, including cognitive reappraisal (Andreotti et al., 2013), as well as strategies that may reflect attempts to regulate emotions but that have serious drawbacks, such as self-criticism (Dunkley, Sanislow, Grilo, & McGlashan, 2009). Researchers have also used self-report measures to gauge individuals’ own perceptions of difficulties with ER, such as feeling overwhelmed or unable to manage emotions. Self-reports of ER difficulties are strongly linked to a range of mental health symptoms. Whereas healthy, flexible ER capacities may serve as a key factor underlying well-being, ER difficulties appear to comprise a transdiagnostic ˜ 1995; Tull, Barrett, risk factor for many mental health problems (e.g., Finlay-Jones, Rees, & Kane, 2015; Gross & Munoz, McMillan, & Roemer, 2007).

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ER difficulties are common among trauma survivors (e.g., Cloitre, Miranda, Stovall-McClough, & Han, 2005), and include lack of ER strategies, not accepting emotions, and lack of emotional clarity (Gratz & Roemer, 2004). Among trauma survivors, ER difficulties are strongly related to PTSD symptoms (Cloitre et al., 2005; Tull et al., 2007; Weiss, Tull, Dixon-Gordon, & Gratz, 2013), and may initiate and maintain PTSD (e.g., Badour & Feldner, 2013). Having a limited repertoire of healthy ER strategies, or unhelpful strategies such as suppression of emotion, is linked with increased PTSD symptoms, including intrusions (Shepherd & Wild, 2014). In addition to increased PTSD, ER difficulties contribute to other adverse outcomes, such as impairments in social relationships, and impaired job performance (e.g., Cloitre et al., 2005). Research models that include ER difficulties demonstrate their direct effects on PTSD symptoms (Sundermann & DePrince, 2015; Mazloom, Yaghubi, & Mohammadkhani, 2016) and their unique associations with a range of mental health difficulties (Tull et al., 2007). As a treatment consideration, psychological interventions that involve building healthy ER strategies or replacing unhealthy ER strategies (e.g., suppression) with healthy ones (e.g., cognitive reappraisal) are associated with meaningful reductions in PTSD symptoms and in related problems (Badour & Feldner, 2013; Tull et al., 2007). ER difficulties have been shown to result from childhood trauma, and to prefigure the development and maintenance of PTSD (Burns, Jackson, & Harding, 2010; Powers et al., 2015; Tull et al., 2007). In addition to their association with increased PTSD symptoms, ER difficulties also contribute to functional impairment (Cloitre et al., 2005), depression and anxiety (Sundermann & DePrince, 2015), and symptom complexity (Choi et al., 2014) among adolescent and adult survivors of childhood abuse. Childhood abuse may set the stage for ER difficulties in several ways: by exposing children to trauma in the absence of strong attachment relationships that could enhance ER skills (Alink et al., 2009); through invalidating environments that teach children that they are wrong in assessing their own emotions and neglecting to provide adequate attention to or care for those emotions (Linehan, 1993); and in caregivers’ failure to model healthy ER strategies. Abusive home environments may influence both the development of ER difficulties and their relation to PTSD symptoms. Goldsmith, Chesney, Heath, and Barlow (2013) found that ER difficulties were associated with high-betrayal types of trauma such as physical, sexual, or emotional abuse perpetrated by someone with whom the victim was very close; however, ER difficulties were not related to low-betrayal traumas such as natural disasters. High-betrayal traumas exerted an indirect effect on symptoms of intrusion and avoidance, as well as symptoms of depression and anxiety via ER difficulties, an effect consistent with mediation. This study and other research (Sundermann & DePrince, 2015) provide support for ER difficulties as a transdiagnostic risk factor that can emerge early in life in abusive home environments, and as an excellent treatment target for the complex emotional sequelae of childhood abuse (Goldsmith et al., 2013). Studies both outside and within the trauma literature indicate that cognitive appraisals and ER are closely connected (Zalewski, Lengua, Wilson, Trancik, & Bazinet, 2011). Neuroscientific research demonstrates that practicing cognitive reappraisals for anxiety-provoking situations activates brain regions involved in regulating anxiety, a result that may reflect how the brain “recruits” resources to help regulate anxiety (Yoshimura et al., 2014). The available research on traumatized populations indicates that appraisals and ER are linked, and that they interact in contributing to PTSD symptoms. For instance, in a sample of students who had been affected by devastating earthquakes, Mazloom et al. (2016) found that ER difficulties had a direct impact on PTSD symptoms, as well as an indirect effect as a mediator between cognitive appraisals and symptoms. An appraisal that emotions are uncontrollable and scary can lead to efforts to avoid emotions in general or to avoid reminders of emotions, a pattern that can elicit PTSD (Tull et al., 2007). However, research investigating how appraisals and ER interact to influence posttraumatic trajectories is scant, and there does not appear to be research investigating how appraisals and ER difficulties jointly influence mental health among survivors of childhood abuse. The current study expands this previous research by linking trauma, difficulties in ER, and appraisals in one study, together with self-compassion. 3. Self-compassion Self-compassion (being caring and kind to oneself, rather than critical, even in challenging moments) may mitigate the negative effects of trauma exposure. A self-compassionate stance offers validation and understanding to oneself in difficult moments, and reflects the perspective that suffering is part of a broader emotional landscape and an inextricable part of being human (Neff, 2003). Self-compassion is strongly positively related to mental health and well-being (MacBeth & Gumley, 2012), as well as to recovery from trauma (Játiva & Cerezo, 2014). Self-compassion is linked with reduced levels of rumination and self-criticism (Mosewich, Crocker, Kowalski, & Delongis, 2013), and with increased self-efficacy, optimism, and resilience (Smeets, Neff, Alberts, & Peters, 2014). Self-compassion is also linked with experiencing fewer PTSD symptoms following natural disasters (Zeller et al., 2015). Like ER, self-compassion may constitute a transdiagnostic mechanism that increases resilience to stressors. Because a self-compassionate stance theoretically relates both to individuals’ attitudes towards themselves and to the coping mechanisms they employ during difficult moments, it seems likely that self-compassion would be associated with both negative trauma appraisals and with ER. Research demonstrates that self-compassion is negatively associated with selfjudgment, self-criticism, rumination, and self-blame (Falconer et al., 2014; Neff, Kirkpatrick, & Rude, 2007), and that training in compassion can reduce shame and self-criticism (Gilbert & Procter, 2006). These findings indicate that self-compassionate individuals may be less likely to develop and maintain negative trauma appraisals, such as shame and self-blame, that have been shown to contribute to PTSD symptoms. A recent study of within-person changes during cognitive therapies for PTSD showed that self-compassion increased over the course of therapy, and self-judgment decreased (Hoffart, Øktedalen, & Langkaas, 2015). Other research shows that self-compassion practice can diminish PTSD, depression, and trauma-related

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guilt (Held & Owens, 2015; Kearney et al., 2013). However, research has not yet examined how self-compassion might relate to a range of trauma appraisals (such as betrayal, anger, and shame about the trauma) beyond the categories of guilt, self-blame, and self-judgment. Research linking self-compassion research to ER is similarly promising, yet limited. Self-compassion has been theorized to be a form of ER (Neff, 2003). Self-compassion appears to activate brain areas that contribute to emotional processing (Hofmann, Grossman, & Hinton, 2011), and has been shown to reduce negative emotions (Arimitsu & Hofmann, 2017). In a study that examined stress among psychologists, self-compassion was related to lower ER difficulties (Finlay-Jones et al., 2015). Among treatment-seeking individuals with PTSD, ER difficulties mediated the relationship between self-compassion and PTSD symptom severity (Scoglio et al., 2015). Self-compassion may lead to greater emotional clarity and acceptance (Finlay-Jones et al., 2015), which may result in fewer negative trauma appraisals and healthier ER strategies. 4. Hypotheses Prior research has examined how trauma exposure and PTSD symptoms relate to negative trauma appraisals, ER, and self-compassion; however, the current study examines these processes simultaneously in order to determine their unique contributions to PTSD symptoms and to investigate the ways that these domains interact. We hypothesized that childhood abuse exposure and PTSD symptoms would be positively associated with negative trauma appraisals and ER difficulties, and negatively associated with self-compassion. In addition, consistent with findings that self-compassion is linked with negative self-evaluation (e.g., Hoffart et al., 2015), we anticipated that self-compassion would have an inverse relationship to negative trauma appraisals. Based on prior research (Finlay-Jones et al., 2015; Goldsmith et al., 2013; Vettese, Dyer, Li, & Wekerle, 2011), we hypothesized that negative trauma appraisals, ER difficulties, and self-compassion would each mediate the relationship between childhood abuse and current PTSD symptoms. To our knowledge, the current crosssectional data provide a unique opportunity to examine trauma appraisals, ER, and self-compassion simultaneously among survivors of childhood abuse. In addition to our specific hypotheses of correlation and mediation, we also aimed to explore any extant complex pathways through which our primary variables of interest (negative trauma appraisals, ER difficulties, and self-compassion) might connect childhood abuse exposure to current PTSD symptoms. 5. Method 5.1. Participants There were 466 participants (322 female; 141 male; 3 did not indicate gender), who were mostly first-year college students. The mean age was 21.21 (SD = 5.83) years. The racial breakdown was: 81.5% White/European American, 9.9% biracial or multiracial, 3.2% Mexican American, 2.6% Asian or Pacific Islander, 1.3% Black/African American, 1.3% “other”, 0.2% Native American. This distribution is representative of the state in which data were collected. 5.2. Materials The Child Abuse Trauma Scale (CAT; Sanders & Becker-Lausen, 1995) is a self-report scale that assesses childhood maltreatment. It has 38 items that yield an overall score as well as subscales that reflect childhood sexual abuse, punishment, neglect, and emotional abuse (Kent & Waller, 1998). The CAT scale does not provide cutoff scores that separate individuals into categories of “abused,” or “non-abused.” Rather, it allows for continuous analyses of childhood maltreatment that reflect the considerable research demonstrating that childhood abuse occurs along a continuum. In college samples, it has demonstrated good test-retest reliability, internal consistency, and discriminant validity. There is little to no difference between genders on the overall scale, although in two college samples women scored twice as high as men on the sexual abuse subscale (Sanders & Becker-Lausen, 1995). The Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004) measures ER difficulties. It has 36 items in six subscales. For each item, participants rate how often each item applies to them. Example items include “When I’m upset, I have difficulty concentrating” and “I experience my emotions as overwhelming and out of control.” Each item is assessed on a 5-point Likert-like scale from “almost never” to “almost always”. In samples similar to ours, the DERS has shown good psychometric properties including internal consistency, test-retest reliability, and construct validity (Gratz & Roemer, 2004). The Trauma Appraisal Questionnaire (TAQ; DePrince et al., 2010) assesses negative trauma appraisals. It has 54 items in 6 subscales: betrayal, self-blame, fear, alienation, anger, and shame. Example items include “I was responsible for what happened” (self-blame), “I lost a piece of myself” (alienation), and “No shower could wash away how dirty I felt” (shame). Each item is rated from 1 (strongly disagree) to 5 (strongly agree). Scores represent the mean of participants’ ratings on each item. Reliability and validity of the TAQ have been demonstrated across a variety of types of samples, including samples diverse in ethnicity, age, and trauma experiences. Internal consistency in the subscales and test-retest reliability have been shown to be excellent (DePrince et al., 2010). The Self-Compassion Scale (SCS; Neff, 2003) assesses people’s perspectives on how they relate to themselves regarding personal challenges and moments of suffering. The SCS includes items about seeing one’s own suffering as part of the greater human condition, as well as items about self-kindness and self-judgment. It has good discriminant validity and test-retest

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Table 1 Means, Standard Deviations, and Correlations among Study Variables.

1 2 3 4 5 6 7 8 9

Child Abuse and Trauma (CAT) total CAT Sexual Abuse CAT Punishment CAT Negative Environment/Neglect CAT Emotional Abuse TAQ Total Mean (Trauma Appraisals) Self-Compassion Scale DERS Total (ER Difficulties) IES Total (PTSD Symptoms)

Mean

SD

1

2

3

4

5

6

7

8

0.87 0.15 1.31 1.00 1.11 1.89 2.96 82.34 29.20

0.60 0.37 0.65 0.79 0.83 0.74 0.70 23.34 17.33

0.52 0.74 0.95 0.91 0.52 −0.33 0.37 0.23

0.25 0.44 0.35 0.38 −0.16 0.24 0.20

0.58 0.66 0.33 −0.20 0.27 0.10

0.84 0.51 −0.33 0.36 0.24

0.46 −0.34 0.36 0.21

−0.47 0.58 0.48

−0.70 −0.33

0.47

Note: If r = ± 0.10, p < 0.05; If r = ± 0.16, p < 0.01; If r = ± 0.20, p < 0.001.

reliability (Neff, 2003), and has been widely used in other studies. There are 26 items, each rated on a scale from 1 to 5. Example items include “I’m kind to myself when I’m experiencing suffering” and “When things are going badly for me, I see the difficulties as part of life that everyone goes through.” Higher scores on the SCS are related to mindfulness as well as to better mental health outcomes (Neff, 2003). The Impact of Event Scale (IES; Horowitz, Wilner, & Alvarez, 1979) is a 15-item measure of symptoms of intrusion and avoidance. It has good construct validity and clinical usefulness. Although it is highly related to PTSD, the IES is not used for diagnosis. Symptoms are rated 0, 1, 3, or 5 where 0 = not at all and 5 = often, within the previous week. Possible ranges are 0–35 for intrusion and 0–40 for avoidance. 5.3. Procedure After providing informed consent, participants at a large, regional university in the United States chose to complete online questionnaires in partial fulfillment of a course requirement. Participants completed the questionnaires anonymously, with credit being given automatically by the system. Therefore, the researchers had no way to link participants’ responses with their identities. The study was approved by the university’s IRB as being in compliance with ethical standards. 5.4. Analysis plan Descriptive statistics and Pearson correlations were used to assess overall levels and interrelationships of the study variables. The PROCESS for SPSS macro (Hayes, 2013) was used to conduct mediation analyses. Model 6 was utilized to assess multiple mediating pathways between the childhood abuse and adult PTSD symptoms, analyze associations among mediating variables, and directly compare the strength of indirect associations. Bootstrapped estimates of indirect associations were utilized. This approach repeatedly samples the dataset to compute estimates of indirect effects. If the 95 percent confidence interval (CI) does not include zero, the association is considered to be statistically significant. This approach helps mitigate bias from non-normal distributions of indirect effects and is more powerful than earlier approaches to statistical mediation testing. 6. Results The mean scores in our sample for childhood abuse (CAT total) and its subtypes (CAT subscales measuring sexual abuse, punishment, neglect, and emotional abuse) were all similar to those found in other college samples (Goldsmith, Freyd, & DePrince, 2009; Kent & Waller, 1998; Sanders & Becker-Lausen, 1995). Because there were no significant gender differences in scores on the study measures, the results reflect the full sample throughout the rest of the paper. The sample’s racial demographics precluded analyses investigating differences related to participants’ racial backgrounds. Means, standard deviations, and correlations among study variables are reported in Table 1. CAT total scores were not highly skewed. The skewness statistic was less than 1.4, indicating that the variable was appropriate for robust models assuming normal distributions. Overall, the pattern of interrelationships was consistent with the study hypotheses. All types of childhood abuse were significantly positively associated with negative trauma appraisals, ER difficulties, and PTSD symptoms, and negatively associated with self-compassion. Self-compassion was negatively associated with trauma appraisals and with ER difficulties. 6.1. Mediation modeling Multiple mediation models were used to explore indirect associations between childhood abuse and PTSD symptoms. Table 2 presents regression models for each of the study variables. Multiple mediation modeling demonstrated that appraisals, ER difficulties, and self-compassion each mediated associations between childhood abuse and PTSD symptoms. The final model (Fig. 1) accounted for 26 percent of the variance in trauma appraisals, 21 percent of the variance in

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Table 2 Regressions Sorted By Outcome Variable.

Coeff.

R2 0.26 SE

F 136.32 T

df1 1 p

df2 383 LLCI

p <0.001 ULCI

1.34 0.63

0.06 0.05

23.55 11.68

<0.001 <0.001

1.23 0.52

1.46 0.73

Coeff.

R2 0.21 SE

F 51.76 T

df1 2 p

df2 382 LLCI

p <0.001 ULCI

3.79 −0.38 −0.13

0.09 0.05 0.06

42.98 −7.48 −2.09

<0.001 <0.001 <0.05

3.62 −0.48 −0.25

3.96 −0.28 −0.01

Coeff.

R2 0.57 SE

F 167.26 t

df1 3 p

df2 381 LLCI

p <0.001 ULCI

117.76 8.60 −18.45 2.91

5.26 1.33 1.26 1.53

22.39 6.45 −14.61 1.90

<0.001 <0.001 <0.001 <0.10

107.42 5.98 −20.94 − 0.11

128.10 11.22 −15.97 5.93

Coeff.

R2 0.31 SE

F 43.03 t

df1 4 p

df2 380 LLCI

p <0.001 ULCI

−10.26 8.03 1.28 0.25 −0.29

7.54 1.32 1.49 0.05 1.45

−1.36 6.07 0.86 5.18 −0.20

0.174 <0.001 0.390 <0.001 0.839

−25.09 5.43 −1.64 0.15 −3.15

4.56 10.63 4.20 0.34 2.56

Outcome: Trauma Appraisals Constant Childhood Abuse

Outcome: Self-Compassion Constant Trauma Appraisals Childhood Abuse

Outcome: ER Difficulties Constant Trauma Appraisals Self-Compassion Childhood Abuse

Outcome: PTSD Symptoms Constant Trauma Appraisals Self-Compassion ER Difficulties Childhood Abuse

Note: df = ◦ of freedom. Coeff. = coefficient. LLCI = lower limit of 95% confidence interval; ULCI = upper limit of 95% confidence interval.

self-compassion, 57 percent of the variance in ER difficulties, and 31 percent of the variance in PTSD symptoms (all ps < 0.001). In analyses accounting for trauma appraisals and self-compassion, childhood abuse was not significantly associated with ER difficulties. Childhood abuse was indirectly associated with PTSD symptoms through five distinct and statistically significant pathways (see Fig. 1). The most direct pathways between childhood abuse and PTSD symptoms were through higher levels of trauma appraisals (Path 1 CI = 2.98–7.33) and ER difficulties (Path 2 CI = 0.01–1.68). Comparison of indirect effects indicated that the indirect association through trauma appraisals was significantly stronger than the indirect association through ER difficulties, CI = 2.06–6.98. Mediation analyses revealed additional indirect associations among the study variables. Childhood abuse was indirectly associated with PTSD through pathways of trauma appraisals and ER difficulties (Path 3 CI = 0.73–2.20), and via self-compassion and ER difficulties (Path 4 CI = 0.01–1.40). The most complex pathway indicated that all study variables were

Self Compassion Trauma Appraisals

Childhood Abuse

ER Difficules

PTSD Symptoms Path 1 CI = 2.98 to 7.33 Path 2 CI = .01 to 1.68 Path 3 CI = .73 to 2.20 Path 4 CI = .01 to 1.40 Path 5 CI = .64 to 1.76

Fig. 1. Final Model with Significant Paths.

Note: CI = 95% Confidence Intervals

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linked to one another through a pathway of trauma appraisals, self-compassion, and ER difficulties (Path 5 CI = 0.64–1.76). Within these indirect pathways, it is of note that self-compassion was not directly associated with PTSD symptoms, but was only indirectly associated with PTSD symptoms through ER difficulties (Paths 2 and 5). Final direct comparison of the 5 significant paths indicated that the pathway of childhood abuse to trauma appraisals to PTSD symptoms was the strongest path. When accounting for these indirect associations, the direct association between childhood abuse and PTSD symptoms was no longer significant (CI = −3.15–2.56), a result indicating that these mediating paths fully explained the association between childhood abuse and adult PTSD symptoms. 6.2. Abuse subscales Analyses were repeated to test whether mediating pathways might vary depending the type of childhood abuse that participants reported. Computational methods were identical to those reported above with the exception that the independent variables were childhood abuse subscales. The analyses demonstrated that appraisals, ER difficulties, and self-compassion each mediated links between every abuse subtype and PTSD symptoms. Childhood sexual abuse was significantly associated with PTSD symptoms through pathways of trauma appraisals (CI = 3.38–8.84), trauma appraisals to ER difficulties (CI = 0.84–2.79), and trauma appraisals to lower self-compassion to ER difficulties (CI =0.76–2.51). Childhood punishment was significantly associated with PTSD symptoms through pathways of trauma appraisals (CI = 1.83–4.49), trauma appraisals to ER difficulties (CI = 0.42–1.34), trauma appraisals to lower self-compassion to ER difficulties (CI =0.39–1.12), and through ER difficulties (CI =0.17–1.48) Childhood neglect was significantly associated with PTSD symptoms through pathways of trauma appraisals (CI = 2.13–5.26), trauma appraisals to ER difficulties (CI = 0.62–1.74), and trauma appraisals to lower self-compassion to ER difficulties (CI =0.51–1.39). Childhood emotional abuse was significantly associated with PTSD symptoms through pathways of trauma appraisals (CI = 1.81–4.61), trauma appraisals to ER difficulties (CI = 0.50–1.52), trauma appraisals to lower self-compassion to ER difficulties (CI = 0.38–1.03), and lower self-compassion to ER difficulties (CI = 0.21–1.20). 6.3. Trauma appraisal subscales Finally, we investigated whether results varied based on trauma appraisal types. Results were highly correlated across the alienation, anger, betrayal, fear, self-blame, and shame subscales. The similarity may be attributable to the fact that trauma appraisals were significantly correlated with each other (r = 0.37–0.70, ps < 0.01). 7. Discussion The current study demonstrated that negative trauma appraisals, ER difficulties, and lower levels of self-compassion are interrelated domains that fully account for the correlation between childhood abuse exposure and current PTSD symptoms in young adults. Consistent with previous research, childhood abuse was associated with higher levels of negative trauma appraisals, increased ER difficulties, lower levels of self-compassion, and increased PTSD symptoms of intrusion and avoidance (Choi et al., 2014; Goldsmith et al., 2013; Sundermann & DePrince, 2015; Vettese et al., 2011). In our model statistically predicting PTSD symptoms from childhood abuse, the indirect association through trauma appraisals was significantly stronger than the indirect association through ER difficulties. This pattern of results suggests that childhood abuse may translate to adult PTSD symptoms by increasing negative trauma-related appraisals and disturbing more general ER processes; however, the impact of trauma-related appraisals may be more potent. The model suggests that childhood abuse may produce a cascade of reactions, including negative cognitions that reduce compassionate attitudes toward oneself, which in turn impair the ability to regulate one’s emotions, which triggers or potentiates PTSD symptoms of intrusion and avoidance. Although our data are cross-sectional and causal conclusions cannot be drawn, this pattern of results is consistent with previous clinical reports and research studies. The results provide new information regarding the relative strength of appraisals, ER difficulties, and self-compassion in predicting PTSD symptoms after trauma, as well as how these processes interact. The data suggest that negative trauma appraisals impact PTSD symptoms both directly and through ER difficulties, while low levels of self-compassion influence PTSD symptoms through ER difficulties. There was a complex association between ER difficulties and childhood abuse, whereby childhood abuse led both directly to ER difficulties and indirectly via trauma appraisals and lower levels of selfcompassion. While previous research has demonstrated the importance of ER in understanding PTSD symptoms following traumas such as childhood abuse (Goldsmith et al., 2013; Sundermann & DePrince, 2015), the current study’s results indicate that appraisals comprise another important mechanism that can lead to intrusions and avoidance. The finding that the pathway between childhood abuse, negative trauma appraisals, and PTSD symptoms was the strongest path is consistent with research demonstrating that appraisals may reflect antecedent-focused coping strategies (that is, appraisals influence what emotions subsequently develop). These strategies may exert more influence than response-focused coping strategies, in which individuals use ER to cope with emotions that are already present (Gross, 1998).

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The present study also contributes new information regarding associations between childhood abuse, reduced selfcompassion, and PTSD symptoms. Findings from this study replicate results from Scoglio et al. (2015) that demonstrated a negative association between self-compassion and ER difficulties; however, they also indicate that low levels of selfcompassion may impact PTSD symptoms by impairing general ER strategies rather than by triggering specific PTSD reactions directly. Self-compassion may help trauma survivors and others in accepting and tolerating difficult emotions (Feliu-Soler et al., 2016), rather than self-criticizing, avoiding or suppressing thoughts. In this way, self-compassion may reduce negative emotions and PTSD symptoms (Tull, Gratz, Salters, & Roemer, 2004). The present study had several limitations. Our sample was predominately white, and included more than twice as many women as men. Although we did not find any gender differences, other studies have shown that cognitive and emotional processes such as ER difficulties may differentially impact PTSD symptoms in ways related to gender and ethnicity (Weiss et al., 2013). Future research should take gender and ethnicity into account during the design and recruitment phases. Our sample of college students also had a limited age range, and future research should be conducted to examine any differences or changes in these processes throughout the aging lifespan. Like many studies of childhood abuse and its links to adult mental health, we relied on participants’ self-reports of symptoms, thought strategies and behaviors, and feelings, and on retrospective self-reports of childhood abuse. While self-report methodology is a valuable tool for examining the effects of childhood abuse, and does not necessarily introduce greater problems than other methods of ascertaining exposure to childhood abuse (Kendall-Tackett & Becker-Blease, 2004), it is similarly vulnerable to reporting errors, especially false negative reports (Fergusson, Horwood, & Woodward, 2000). It is possible that structured clinical interviews with skilled clinicians would have uncovered more, fewer, or different symptoms and experiences than those that participants were able to report on a questionnaire. In addition, mediation models should be interpreted cautiously as possible pathways and not as definitive causal influences, given that the data were cross-sectional. Any statistical approach, including the present analyses, is vulnerable to type I error. However, the PROCESS macro’s Model 6, used for the main analyses, takes alpha levels into account in its calculations. It is also of note that we focused on the PTSD symptoms of intrusion and avoidance as measured by the IES, rather than the diagnostic construct of PTSD as defined by the DSM. Our transdiagnostic approach investigates symptoms rather than disorders per se. The current study also did not include additional variables, such as social support and subsequent interpersonal violence, which have been shown to influence the relationship between childhood abuse exposure and PTSD symptoms (Stevens et al., 2013). These results are most applicable to adults from a general non-clinical population within the United States. The present research focused on PTSD symptoms; however, it is likely that appraisals, ER difficulties, and self-compassion would influence additional symptom domains such as depression, anxiety, panic, and suicidality (Goldsmith et al., 2013; Zeller et al., 2015). 8. Conclusions These results can inform treatment by underscoring the importance of appraisals, ER, and self-compassion in maintaining PTSD symptoms and in promoting recovery. Multiple treatment paradigms for trauma survivors demonstrate meaningful reductions in PTSD symptoms, though their emphases diverge to accentuate appraisals (e.g., Cognitive Processing Therapy [CPT]; Chard, 2005); emotion regulation (e.g., Dialectical Behavior Therapy [DBT]; Neacsiu, Eberle, Kramer, Wiesmann, & Linehan, 2014), or self-compassion (e.g., Loving-kindness Meditation; Kearney et al., 2013). The current research also deepens clinical reports showing that addressing any of appraisals, ER, or self-compassion leads to shifts among the other domains. For instance, cognitive therapies for PTSD symptoms not only reduce negative trauma appraisals, but increase self-compassion (Hoffart et al., 2015; Schumm et al., 2015). Experimental research in nonclinical populations also indicates that self-compassion may boost the efficacy of cognitive reappraisals (Diedrich, Hofmann, Cuijpers, & Berking, 2016). Any clinical approach must be personalized to the trauma survivor’s needs and issues. It may be tempting to interpret the current result that appraisals contribute to PTSD symptoms more strongly than do ER difficulties or self-compassion as indicating that clinical approaches should prioritize this internal domain above ER or self-compassion. However, there are several relevant issues that preclude that assumption. First, clinicians must attend to issues of safety and stabilization among their patients before addressing PTSD symptoms; treatments that focus on building ER and other skills may be especially useful here. Second, childhood abuse is associated with heterogeneous symptoms, and it may be wisest to match treatment approaches to each person’s presentation. Third, addressing negative trauma appraisals too soon may backfire. For survivors of childhood abuse, hearing the possibility that their abuse experiences and their current psychological difficulties do not mean that they are defective, bad, or at fault can seem so remote as to be almost invalidating. Offering ER strategies might have more face value in terms of matching specific skills to patients’ presenting concerns, an attribute that may thereby improve treatment adherence and completion rates, especially as fear of emotions has been shown to contribute to dropout rates for trauma treatment (Miles, Smith, Maieritsch, & Ahearn, 2015). Fourth, trauma survivors usually present with other concerns in addition to PTSD symptoms, and treatments such as DBT that focus on ER skills also reduce anxiety, depression, substance use, and suicidality (Neacsiu et al., 2014). Because extant research has not compared or dismantled therapies that focus on trauma appraisals (e.g., CPT), emotion regulation (e.g., DBT), and self-compassion (compassion-focused therapy; Gilbert, 2009), we cannot infer that one of these strategies is more effective than the others. The available research, including the present project, indicates that clinicians who treat childhood abuse

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would benefit from a sensibility to the ways that trauma appraisals, ER difficulties, and levels of self-compassion each impact PTSD symptoms and may interact to influence psychological difficulties and recovery. Another important consideration involves the relational contexts in which childhood abuse occurs and in which negative trauma appraisals, ER, and levels of self-compassion develop—and through which recovery can occur. Common factors in therapy such as empathy, trust, warmth, therapists’ levels of skill and knowledge, and perceived strength of the relationship may shift negative trauma appraisals and improve well-being to far greater extent than the type of treatment provided (Dalenberg, 2014). Despite the strength of this evidence, common factors are all too frequently left out of treatment research (Dalenberg, 2014). Researchers and clinicians may benefit from considering a range of cognitive and emotional tendencies that influence distress among trauma survivors, including negative trauma appraisals, ER, and self-compassion. Subsequent research should address the generalizability of these results by assessing these factors among samples more diverse with respect to ethnicity, culture, age, education, and to additional types of trauma exposure. Future studies can also link research on negative trauma appraisals such as shame, blame, and alienation (DePrince et al., 2011) with coping-related appraisals such as growth or resilience mindsets. Abuse alone does not sentence a person to PTSD. Through careful attention to negative trauma appraisals, ER difficulties, and self-compassion, both childhood abuse survivors and mental health professionals can create positive changes, effect trauma recovery, and build future well-being and resilience. 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