Are guilt and shame linked to treatment motivation and readiness?

Transcription

1 Are guilt and shame linked to treatment motivation and readiness? An empirical investigation Jeannette Harris, Dr Simon Draycott and Dr James Tapp (and with thanks to all the participants who gave their time to support this research)

2 Background Motivation and readiness for treatment are thought to play key role in the completion and outcome of treatment. There are different conceptualisations of motivation and readiness and these terms are used interchangeably. The terms are also confused with other concepts, such as treatment participation and engagement.

3 Definitions Term used Motivation to change Motivation for treatment Treatment readiness Treatment engagement Definition Offered Being ready, being willing and being able to make a change (Viets, Walker & Miller, 2002). Being motivated to participate in therapy or a treatment programme (DiClemente, 1999). An internal factor which pushes someone to engage in a particular behaviour, such as engaging in treatment (Drieschner, Lammers and van der Staak (2004). Internal and external characteristics that facilitate and promote engagement in therapy (McMurran & Ward, 2010) and facilitate therapeutic change (Howells & Day, 2007). 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).

4 Motivation There are general theories of motivation to change, which have been applied to offending behaviour. There are also models which focus specifically on motivation for treatment, rather than motivation for change more generally. Drieschner, Lammers & van der Staak (2004) developed one such model, which has also been supported as a way of understanding motivation in offender populations.

5 Model of Motivation Treatment Circumstances Problem characteristics Events MET TE Treatment Outcome Demographic Factors L Limitations to Treatment Volitional control efficacy Kind of problem KEY: PR = Problem Recognition, LS = Level of Suffering, EP = External Pressure, CT = perceived Costs of Treatment, ST = perceived Suitability of Treatment, OE = Outcome Expectancy, MET = Motivation to Engage in Treatment, TE = Treatment Engagement Figure 1. Drieschner et al. s (2004) conceptualisation of treatment motivation and related concepts.

6 Readiness Differentiated from motivation by Ward, Day, Howells and Birgen (2004): - Motivation = volition whether someone really wants to enter treatment and is willing to change behaviour VERSUS - Readiness = internal and external characteristics that can promote treatment engagement. Ward et al. developed the Multifactor Offender Readiness Model (MORM) to define the readiness characteristics.

7 MORM Figure 2. Ward et al. s (2004) Multifactor Offender Readiness Model (MORM).

8 Forensic Patients Both models have been applied to help understand motivation and readiness in populations of offenders with mental health difficulties. However, there are specific considerations for this group: i. Dual role of treatment (improving mental health and addressing offending behaviour) ii. iii. iv. Direct role of mental health on beliefs, mood and ability to manage stress Limited inter- and intra-personal resources Complexities of developing therapeutic relationships

9 Guilt and Shame Both models note role of guilt and shame. Lewis (1971) and June Tangney define these terms as: - Guilt = focus on the behaviour - Shame = focus on the self Traits and states Maybe particularly relevant to forensic patients? Contributory factors for experiencing shame have high prevalence in this group and shame linked with a number of mental health difficulties (Tangney, Wagner & Gramzow, 1992).

10 Guilt and Shame and Motivation and Readiness Both models incorporate these into the internal factors of motivation and readiness Drieschner et al. s model = included in Level of Suffering factor. Suggests both emotions are relevant but does not specify how either help or hinder motivation. MORM = shame may inhibit readiness, whereas guilt could assist with readiness. Conceptualisations of guilt and shame also suggest guilt tends to lead to reparative actions, whereas shame is linked to desire to hide, escape and externalise blame (Tangney et al., 2011; Tangney, Stuewig & Martinez, 2014).

11 Rationale Role of shame in mental health and treatment motivation and readiness Literature review no direct empirical evidence exploring role of guilt and shame in motivation and readiness with forensic patients Therefore, it is not yet known whether (or how) guilt and shame are applicable in motivation and readiness for forensic patients

12 Research Questions 1. Is shame-proneness a more common experience than guilt-proneness in forensic patients? Is proneness to these feelings related to offence-related guilt or shame? It is not yet understood whether forensic patients will be more prone to shame than guilt, nor whether this will be related to guilt or shame about offending behaviour. 2. Is there a relationship between guilt and shame, and motivation and readiness? Is there any difference between the experience of guilt and the experience of shame on motivation and readiness? It is hypothesised that guilt feelings will increase motivation and readiness to participate in treatment, whereas shame will inhibit motivation and readiness.

13 Method Participants: - 66 men recruited from high and medium secure units in the UK. - Mean age (SD=9.77, range 23 65). - Most were based on assertive rehabilitation wards. - Mean time in hospital was 4.48 years (SD=5.03, range ). - Nearly all (90.9%) had engaged in at least one group or individual therapy.

14 Index Offence N (%) Diagnosis N (%) Murder / manslaughter 21 (31.8%) Psychosis 27 (40.9%) Violent offence 18 (27.3%) Mood Disorder 1 (1.5%) Sexual offence 4 (6.1%) Personality Disorder 8 (12.1%) Mixed violent and sexual offence 3 (4.5%) Mixed diagnosis 27 (40.9%) Arson 9 (13.6%) Theft / acquisitive offence 3 (4.5%) Missing 3 (4.5%) Other 5 (7.6%) Missing 3 (4.5%)

15 Method Design: - Cross-sectional correlational design - Exploratory variables were guilt and shame (proneness and offence related) - Outcome variables were motivation and readiness Measures: - Test of Self Conscious Affect Socially Deviant Version (TOSCA-SD; Hanson & Tangney, 1995) - Offence Related Shame and Guilt Scale (ORSGS; Wright & Gudjonsson, 2007) - Patient Motivation Inventory (PMI; Gudjonsson, Young & Yates, 2007) - Treatment Readiness Questionnaire (Casey, Day, Howells & Ward, 2007) - Treatment Readiness, Responsivity and Gain Scale: Short Version (TRRG:SV; Serin, Kennedy, & Mailloux, 2005) only the Readiness subscale was used.

16 Results Question 1: TOSCA-SD Shame Proneness TOSCA-SD Guilt Proneness TOSCA-SD Shame Proneness - General Forensic Population TOSCA-SD Guilt Proneness - General Forensic Population

17 Question 2: Scale TOSCA- SD Shame ORSGS Shame TOSCA-SD Guilt ORSGS Guilt PMI TRQ TRS TOSCA-SD Shame -.315**±.288*±.263*± ORSGS Shame **± *.130 TOSCA-SD Guilt *.201 ORSGS Guilt -.333**.427**.383** PMI TRQ TRS -.460**.336* N *± Correlation is significant at the 0.05 level (2-tailed) * Correlation is significant at the 0.05 level (1-tailed) **± Correlation is significant at the 0.01 level (2-tailed) ** Correlation is significant at the 0.01 level (1-tailed)

18 PMI MOTIVATION Multiple Regression Beta Sig R Square Adjusted R Square Sig Full Model TOSCA Shame ORSGS Shame TOSCA Guilt ORSGS Guilt Model 2 ORSGS Shame TOSCA Guilt ORSGS Guilt Model 3 ORSGS Shame ORSGS Guilt Model ORSGS Guilt

19 TRQ READINESS Beta Sig R Square Adjusted R Square Sig Full Model TOSCA Shame ORSGS Shame TOSCA Guilt ORSGS Guilt Model 2 ORSGS Shame TOSCA Guilt ORSGS Guilt Model 3 TOSCA Guilt ORSGS Guilt Model ORSGS Guilt

20 TRS READINESS Beta Sig R Square Adjusted R Square Sig Full Model TOSCA Shame ORSGS Shame TOSCA Guilt ORSGS Guilt Model 2 ORSGS Shame TOSCA Guilt ORSGS Guilt Model 3 TOSCA Guilt ORSGS Guilt Final Model ORSGS Guilt

21 Discussion Higher guilt-proneness than shame maybe a result of shame being more difficult to articulate than guilt? Both guilt and shame-proneness were higher than in the general forensic population why? Guilt-proneness was not as highly associated with offence-related guilt than had been found in previous research differences in measurement, differences in sample?

22 Discussion Offence-related guilt only variable significantly predicting readiness (and nearly motivation) small amount of variance explained by this, as would be expected from multi-factors thought to be involved in motivation and readiness. No relationship between shame and motivation and readiness due to lower levels of reported shame, amount of time elapsed since offence, low power to detect effects or could it be that shame does not have a negative relationship with motivation and readiness. Some support for motivation and readiness models, and conceptualisations of guilt and shame, but more research may be needed to explore this.

23 Limitations Measures lower internal consistency, difficulty measuring complex experiences, cross-over between measures Correlation, so no causality can be assumed Sample heterogeneity Treatment engagers Smaller sample size than required so findings may be affected by power

24 Implications Assessing for offence-related guilt to inform formulations of motivation and readiness Considering ways that interventions could be structured so guilt about offending into thinking about change (i.e. restorative justice approaches?) Validating and adapting measures to suit this population Prospective / qualitative research to further explore these factors Looking at demographic factors to see if there are relevant confounding factors

25 References Casey, S., Day, A., Howells, K. & Ward, T. (2007). Assessing suitability for offender rehabilitation: Development and validation of the Treatment Readiness Questionnaire. Criminal Justice and Behaviour, 34 (11), DOI: / Cohen, J. (1992). A power primer. Psychological Bulletin, 112, DiClemente, C. C. (1999). Motivation for change: Implications for substance abuse treatment. Psychological Science, 10 (3), Doi: / Drieschner, K. H., Lammers, S. M. M. & van der Staak, C. P. F. (2004). Treatment motivation: An attempt for clarification of an ambiguous concept. Clinical Psychology Review, 23, Gudjonsson, G. H., Young, S. & Yates, S. (2007) Motivating mentally disordered offenders to change: Instruments for measuring patients' perception and motivation. The Journal of Forensic Psychiatry & Psychology, 18 (1), DOI: / Hanson, R. K. & Tangney, J. P. (1995). The Test of Self-Conscious Affect Socially Deviant Populations (TOSCA-SD). Ottawa: Corrections Research.

26 Howells, K. & Day, A. (2007) Readiness for treatment in high risk offenders with personality disorders. Psychology, Crime and Law, 13 (1), Krause, M. S. (1967). Behavioural indexes of motivation for treatment. Journal of Counselling Psychology, 14, Lewis, H. B. (1971). Shame and guilt in neurosis. Connecticut: International Universities Press. McMurran, M. & Ward, T. (2010). Treatment readiness, treatment engagement and behaviour change. Criminal Behaviour and Mental Health, 20 (2), Doi: /cbm.762. Serin, R., Kennedy, S. & Mailloux, D.L. (2005). Manual for the Treatment Readiness, Responsivity and Gain Scale: Short Version (TRRG:SV). Ottawa: Carleton University. Tangney, J. P., Stuewig, J. & Martinez, A. G. (2014). Two faces of shame: The roles of shame and guilt in predicting recidivism. Psychological Science, 25 (3),

27 Tangney, J. P., Stuewig, J., Mashek, D. & Hastings, M. (2011). Feeling bad about the behaviour or the self? Assessing jail inmates proneness to shame and guilt. Criminal Justice and Behaviour, 38, Tangney, J. P., Wagner, P. & Gramzow, R. (1992). Proneness to Shame, Proneness to Guilt, and Psychopathology. Journal of Abnormal Psychology, 101 (3), Viets, V. L., Walker, D. D. & Miller, W. R. (2002). What is motivation to change? A scientific analysis. In, M. McMurran. (Ed.). Motivating offenders to change: A guide to enhancing engagement in therapy. Chichester: John Wiley & Sons. Pp Wright, K. & Gudjonsson, G. H. (2007). The development of a scale for measuring offencerelated feelings of shame and guilt. The Journal of Forensic Psychiatry & Psychology, 18 (3),