Are Guilt and Shame in Male Forensic Patients Linked to Treatment Motivation and Readiness?

Are Guilt and Shame in Male Forensic Patients Linked to Treatment Motivation and Readiness?

Jeannette Fuller

Submitted for the Degree of

Doctor of Psychology

(Clinical Psychology)

School of Psychology

Faculty of Health and Medical Sciences

University of Surrey

Guildford, Surrey

United Kingdom

September 2017

Statement of Originality

This thesis and the work to which it refers are the results of my own efforts. Any ideas, data, images, or text resulting from the work of others (whether published or unpublished) are fully identified as such within the work and attributed to their originator in the text. This thesis has not been submitted in whole or in part for any other academic degree or professional qualification.

Name: Jeannette Fuller

Overview

This thesis includes the research, assignments and clinical placements that were undertaken for the degree of Doctor of Psychology (Clinical Psychology). The Major Research Project was focused on the concepts of guilt and shame and treatment motivation and readiness in forensic patients.

Treatment motivation and readiness are important considerations in forensic settings. Models and theories of these concepts suggest affective factors such as the experience of guilt and shame are likely to have some impact on motivation and readiness for treatment. These models have been validated in general forensic settings, but although applied to forensic mental health settings, the validity of the different aspects of these models has not been directly examined with forensic mental health patients. This thesis aimed to investigate whether there was any relationship between guilt and shame and motivation and readiness for treatment in a sample of forensic patients. Part one of this thesis presents a narrative review of guilt and shame in forensic mental health participants. The findings of the review suggested that guilt and shame were relevant emotional experiences for forensic patients. Links between these emotions and motivation and readiness for treatment had not been empirically tested. Part two presents an empirical paper that investigated the association between guilt and shame and treatment motivation and readiness in patients residing in forensic mental health settings. The findings suggested that offence-related guilt was associated with readiness for treatment, whereas shame did not have a relationship with motivation or readiness.

Part three presents a summary of clinical experience gained within this training programme and Part four contains the assessments completed during training.

Publications

Parts of this thesis have been presented at:

• The British Psychological Society (BPS) Division for Forensic Psychology (DFP) Annual Conference 2017 (14th June 2017).

Contents

Statement of OriginalityPage 2

Overview Page 3

PublicationsPage 4

AcknowledgementsPage 6

Part One: Literature ReviewPage 8

Part Two: Empirical PaperPage64

-List of appendices for the empirical paperPage 113

-Appendices for the empirical paperPage 114

Part Three: Summary of Clinical ExperiencePage 139

Part Four: Table of Assessments Completed During Training Page 143

Acknowledgements

I would like to thank all those who have supported me during my training. I would not have survived the last three years without the encouragement and guidance of the staff on the PsychD programme. In particular, my thanks go to my research supervisors, Dr Simon Draycott and Dr James Tapp, for all the help they provided throughout the project and for keeping me motivated right to the very end. They have given up their time to support me when I was losing the wood for the trees and on the rollercoaster of data collection and analysis. I would also like to acknowledge the support of my clinical tutor, Dr Melanie Smart, who has helped me to develop and gain confidence across the three years of training. I am also extremely grateful to the entire cohort who have shared knowledge, skills, and resources and been supportive at all times. I think we have made a great team and feel extremely fortunate that I have also made some fantastic friends.

I would like to acknowledge the research participants who gave up their time and shared their experiences with me, and I am very grateful to the psychology students who shared ideas with me and who assisted with the administration associated with data collection and analysis.

I would like to thank all of the teams and supervisors that I have worked with during the course of training. I have been encouraged and supported by all the professionals who have welcomed me into their services and I am truly grateful for the opportunity to work with such great people. I have learnt a great deal from all my clinical supervisors, Dr Sarah Worden, Joanne Morris-Smith, Julie Lloyd, Dr Simon Wels and Dr Aaron Richards. They have taught me not only how to be a clinical psychologist, but also helped me develop both personally and professionally and have shown me the type of supervisor and colleague I would like to be.

Last, and by no means least, I am very thankful for all my family and friends who have supported me, not only during the last three years, but in all the time I have been working towards this qualification. These last three years have been the most stressful and challenging and without their support I would not have completed this training programme. They understood when I was bad-tempered and unavailable and continued to be there despite this. In particular, I would like to acknowledge the long-suffering Rob, who has made numerous meals and kept everything going when I let things slide, and who has carried me in my more emotional moments – I could not have done this without him. I amindebted to my mum, dad, Nan, brother, uncle and my (soon-to-be) in-laws for showing ongoing interest and helping me celebrate the successes and pushing me through the challenges. I also want to thank my closest friend, Sarah, who has been alongside me throughout the entire process of education and training, never doubting me and always telling me I can do it! Finally, this thesis is dedicated to my grandad, who passed away before he was able to see me progress through this course, but who I hope I have made proud.

PART ONE

How are Guilt and Shame in Male Adult Offenders with Mental Health Difficulties Linked to Treatment Motivation and Readiness?

A Review of the Literature

Abstract

Background: Motivation and readiness for treatment in offender populations are important areas of research. Models have been developed to consider the factors that may impact on treatment motivation and readiness. These suggest that guilt and shame play a role in an individual’s motivation and readiness for treatment. The affective factors included in these models have been validated with general forensic populations. Less appears to be known about the role of guilt and shame in specific forensic mental health populations.

Aims: This review aimed to identify the existing research literature that has investigated guilt and shame in offenders who have mental health difficulties in the context of treatment motivation and readiness.

Method: Social science databases were searched using identified search terms and articles screened according to inclusion criteria developed for this review. Following screening, key data was extracted from relevant studies, quality was assessed and themes from findings were described.

Results: After screening, 11 studies were included. The main themes found in research were related to blame attribution, shame and guilt responses to offending and the role of trauma within these responses. Theoretical links between guilt and shame and treatment readiness and motivation were made.

Discussion: The variance of topics, samples and measures used in the available research made firm conclusions difficult. Further research may be needed to explore guilt and shame, as well as their relationship between motivation and readiness and guilt and shame in this population.

1

Introduction

The ‘What Works’ literaturefocuses on psychological treatment for forensic populations (McGuire, 1995). Over the last 20 years there has been significant research attention on the effectiveness of treatment programmes at reducing recidivism (Grimwood & Berman, 2012), especially due to the significant cost of reoffending (Home Office, 2013). Motivation and readiness to engage in treatment are prominent themes in this research, with these factors being implicated as important aspects of treatment outcome (Debidin & Lovbakke, 2005; Ward, Day, Howells & Birgen, 2004). Therefore, questions arise about what is classed as adequate motivation and readiness and how these can be assessed and measured. One potential difficulty with developing theories about motivation and readiness is that these concepts are hard to define. A number of terms are used interchangeably when discussing motivation in the context of treatment (including engagement, readiness and responsivity) but these are argued to have different definitions. Some of the definitions used are summarised in Table 1.

Table 1. Some definitions offered for the concepts of motivation and readiness

Term used / Definition Offered
Motivation to change / Being ready (seeing change as a priority),
being willing (seeing a need to change) and being able (self-efficacy, hope and self-regulation; Viets, Walker & Miller, 2002) to make a change.
Motivation for treatment / While motivation to change refers to motivation to make global changes in thoughts and actions, motivation for treatment refers to being motivated to participate in therapy or a treatment programme (DiClemente, 1999). Drieschner, Lammers and van der Staak (2004) define motivation as an internal factor which pushes someone to engage in a particular behaviour, such as engaging in treatment.
Treatment readiness / Internal and external characteristics that facilitate and promote engagement in therapy (McMurran & Ward, 2010) and facilitate therapeutic change (Howells & Day, 2007).
Treatment engagement / This is argued to be difficult to define (Drieschner et al., 2004), but some reference has been made to behaviours expected by the therapist, such as attending and utilising treatment sessions, being open about problems, using therapist contributions and working in between treatment sessions (Krause, 1967). It is unclear about how this may differ from treatment participation which is also a term used interchangeably with engagement.

Theories about motivation and readiness have been developed in other areas, such as substance misuse, smoking cessation and physical health (with one of the most commonly applied being the ‘Stages of Change model’; Prochaska & DiClemente, 1982), which have been applied to offending behaviour (Tierney & McCabe, 2001). However, it has been argued that these models do not sufficiently explain motivational factors in forensic populations and ignore contextual factors by overemphasising individual decision-making (Burrowes & Needs, 2009). A model of treatment motivation that has been applied to forensic populations was developed by Dreischner et al. (2004). This model was designed specifically to explain motivation for treatment, rather than more general motivation for change. The model stresses that only behaviour under an individual’s chosen control can indicate motivation and thus emphasises internal factors such as emotions and perceptions (Figure 1). Some support has been shown for this as a way of understanding treatment motivation with people who have committed offences (Drieschner, & Verschuur, 2010).

[Figure 1 here – removed due to copyright]

Figure 1. Drieschner et al.’s (2004) conceptualisation of treatment motivation and related concepts.

In an attempt to explain the different concept of treatment readiness specifically with forensic populations, Ward et al. (2004) developed the Multifactor Offender Readiness Model (MORM). The MORM incorporates both internal and external factors which are suggested to interact to either increase or decrease both engagement with treatment programmes and performance within these. This model is presented in Figure 2.

Neither model was specifically designed to explain treatment motivation and readiness in populations of offenders who also experience mental health difficulties. There are thought to be specific considerations for these individuals, such as the dual role of treatment (at restoring mental health as well as addressing offending risk) and the complexities of forming supportive relationships with professionals and others (Hodge and Renwick, 2002).

[Figure 2 here – removed due to copyright]

Figure 2. Ward et al.’s Multifactor Offender Readiness Model (MORM).

While these two models do not specifically focus on mental health factors, they do suggest that affective factors can play a role in an individual’s ability to engage in treatment. Drieschner et al.’s model notes that experiences of guilt and shame are linked tomotivation to engage in treatment, but does not further clarify whether these emotions can help or hinder engagement. The MORM suggests that shame may inhibit readiness whereas feeling guilt leads to attempts to understand the offence and therefore could assist with readiness to engage in treatment that would prevent this from being repeated in the future.

Guilt and Shame

Guilt and shame are terms that are often used interchangeably; while they are both emotions of self-blame (Tangney, 2000a) there are thought to be important differences in how these emotions are experienced. These emotions are thought to be complex (Morgan, 2008)and there are a number of conceptual arguments about how these are defined and how these emotions differ. Some researchers have distinguished guilt from shame in terms of the situations which cause them, suggesting that public exposure and disapproval can lead to shame, whereas self-generated concerns lead to guilt (Wortley, 1996). However, research has not generally supported this notion. One main model of distinguishing between these two experiences is to consider whether the focus is on the self (for shame) or on the behaviour (for guilt; Lewis, 1971; Tangney, Miller, Flicker & Barlow, 1996; Terroni & Deonna, 2008). This conceptualisation has been well supported by empirical research (Tangney & Dearing, 2002).

Using this conceptualisation, guilt (without accompanying shame) has been found to be largely unrelated to psychological difficulties, whereas shame has been linked to a number of mental health difficulties, including depression, anxiety, eating disorders and low self-esteem (Tangney & Dearing, 2002; Tangney, Wagner & Gramzow, 1992). Tangney et al. (1992) found that shame-prone individuals appeared vulnerable to depressive symptoms, above and beyond what would be expected from attributional style. However, most research in this area has used correlational designs so it is not possible to state whether shame was a cause of mental health difficulties.

It is argued that these two emotions can lead to different responses; shame has been linked to tendencies to externalise blame, deny or escape shame-inducing situations, whereas guilt can lead to tension, remorse and regret, which can motivate action to repair the harm that has been caused (Tangney, 2000a; Tangney, StuewigHafez, 2011). Shame can be more difficult to detect than guilt, as it is not often articulated, mainly thought to be a result of a desire for concealment (Tangney, 2000b). Tangney has been a prominent researcher in this area, and many of her findings have suggested that ‘shame-free’ guilt tends to be adaptive due to its tendency to lead to reparative actions, whereas shame triggers a sense of being personally defective that leads to high levels of distress and defensiveness which results in rumination, anger and scapegoating (Stuewig, Tangney, Heigel, Harty & McCloskey, 2010; also supported by Boudewyns, Turner & Paqin, 2013).

These emotions are likely to have some impact on motivation and readiness to participate in treatment and therapy. Shame responses are likely to be counter to motivation and readiness; denial, externalisation of blame and high distress that are associated with shame would be at odds with the factors identified as being related to treatment motivation and readiness. Further to this, Tangney and Dearing (2002) note that the therapy context can lend itself to the experience of shame, where an individual may feel exposed and personally defective in this setting. Shame is thought to be linked to some of the difficulties that can lead someone into therapy, but those who could benefit from this do not feel able to utilise this (Fee, 1998). The experience of therapy can be shaming for those who do overcome the barriers to engaging in this, and shame-induced withdrawal may occur. As shame is conceptualised as leading to stable and global negative attributions to the self, it is implied that it could prevent individuals being able to change the self and behaviour (Baumeister & Bushman, 2003). Taking this research and theory into account, it would be expected that shame would reduce both motivation and readiness for treatment and psychological therapy.

Guilt on the other hand is thought to motivate people to admit wrong-doings, which leads to attempts at reparative actions (Tangney, 2002). As this emotion does not result in the same global, stable and negative attributions to the self, this may mean that individuals feel more able to make changes and therefore more likely to be motivated and ready to engage in treatment to support these changes. Using this conceptualisation of guilt, it is likely that the drive to repair may also lead to a desire towards making changes to prevent a reoccurrence of a harmful action, which again could motivate someone to engage in treatment to assist this.However, some conflicting evidence has emerged suggesting that shame can also motivate change at the same time as driving a distancing from the situation (Lickel, Kushlev, Savalei, Matta & Schmader, 2014). This concept of shame as a motivator for change versus driving avoidance has been explained in terms of whether the episode which triggered the event was perceived as reparable or not (Leach & Cidam, 2015). The picture of shame and guilt and motivation is therefore not clear.