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Do Immature Defense Mechanisms Mediate the Relationship Between Shame, Guilt, and Psychopathological Symptoms?

Do Immature Defense Mechanisms Mediate the Relationship Between Shame, Guilt, and... ORIGINAL RESEARCH published: 03 May 2022 doi: 10.3389/fpsyg.2022.832237 Do Immature Defense Mechanisms Mediate the Relationship Between Shame, Guilt, and Psychopathological Symptoms? Cesare Cavalera *, Paolo Andreani , Oliver Baumgartner and Osmano Oasi Deparment of Psychology, Università Cattolica del Sacro Cuore, Milan, Italy When shame and guilt emotional experiences related to stressful events remain unresolved, they can be  related to psychological impairment and recursive thoughts. The present study aims to explore the association between state shame and state guilt related to past stressful experiences and psychopathological symptoms and evaluating a mediation role by immature defenses. A total of 90 participants (48.9% female; mean age 23.66) were considered in the present study to (a) investigate correlations between state guilt and shame scores related to personal stressful events and psychopathological symptoms Edited by: related to global severity index; (b) assess whether state guilt and shame scores related Leonardo Carlucci, University of Studies G. d’Annunzio to personal stressful events are positively correlated with immature defenses; (c) test Chieti and Pescara, Italy whether immature defenses mediates the relationship between, respectively, state shame Reviewed by: and state guilt with psychopathological symptoms. Significant correlations between state Diana Nechita, Babes-Bolyai University ̦ , Romania shame, state guilt, psychopathological symptoms, and immature defenses were found. Braj Bhushan, Higher activations on immature defenses partially mediated the relationship between Indian Institute of Technology Kanpur, psychopathological symptoms and state shame and state guilt, respectively. Past India experiences related to shame and guilt should be targeted by specific treatments that *Correspondence: Cesare Cavalera could help stop recursive maladaptive thoughts and empower more adaptive cesarem.cavalera@unicatt.it defensive strategies. Specialty section: Keywords: defense mechanism, shame, guilt, symptoms severity, self-conscious emotions This article was submitted to Psychology for Clinical Settings, a section of the journal Frontiers in Psychology INTRODUCTION Received: 09 December 2021 Traumatic and Psychopathological Implications of Shame and Accepted: 28 March 2022 Published: 03 May 2022 Guilt Trauma and memories of trauma can be  related to unresolved negative emotions with serious Citation: Cavalera C, Andreani P, consequences for quality of life and psychological balance (Vaillant, 1994; Dorahy et  al., 2017). Baumgartner O and Oasi O (2022) Guilt and shame are distinctive negative self-conscious emotions that, due to their nature, can Do Immature Defense Mechanisms be  related to traumatic experiences (American Psychiatric Association, 2013; Cavalera et  al., Mediate the Relationship Between 2018). Despite the fact they have many aspects in common (i.e., both originate from relevant Shame, Guilt, and transgression and failure of oneself), they differ in their trajectories. While guilt implies self- Psychopathological Symptoms? criticism of a specific personal action and it is associated with the damage it may have caused Front. Psychol. 13:832237. doi: 10.3389/fpsyg.2022.832237 to others, shame is the consequence of a negative self-evaluation (Tracy and Robins, 2006). Frontiers in Psychology | www.frontiersin.org 1 May 2022 | Volume 13 | Article 832237 Cavalera et al. Defense Mechanisms, Shame, and Guilt While feeling of shame are linked to a stable internal and impairing working memory process (Cavalera et  al., 2018) negative perception of the entire self (e.g., “I’m a bad person”), and with emotional dysregulation defined both in terms of guilt appears when people attribute an adverse outcome to overwhelming sensations and in terms of excessive deactivation internal, unstable, and controllable attributions (e.g., “I’ve made (Rugens and Terhune, 2013; Dorahy et al., 2017). Unresolved a bad mistake”). er Th efore, shame is associated with feelings state guilt or shame related to traumatic experiences may of inferiority and worthlessness for a defective self with the therefore cause panic, terror, or a sense of urgency (Breggin, consequent desire to hide or escape from a bad situation, 2015). On the other hand, excessive deactivation of emotions while guilt is associated with feelings of tension and remorse may cause depersonalization and derealization, or dissociative related to a wrong behavior (Tracy and Robins, 2006). As emotional numbing in such contexts that intensified emotions shame is intrinsic to social subordination, recursive shameful would be expected to occur (Pur, 2014). Rugens and Terhune experiences may be  related to thoughts that reflect a defective (2013) evidenced the role of guilt in augmenting the self. Maladaptive guilt may be also related to impairing thoughts relationship between dissociative tendencies and state of hyper-responsibility and self-criticism that occurs in dissociation. Similarly, State shame was also found to be  a interpersonal situation (Cavalera, 2020). Therefore, when shame significant predictor of dissociative symptoms in complex and guilt related to stressful event remain unresolved, they PTSD (Dorahy et  al., 2017). can readily be elicited in everyday situations causing psychological impairment and recursive thoughts (Irwin, 1998; Dorahy Shame, Guilt, and Immature Defenses et  al., 2017). Defense mechanisms play a central role in mitigating the Different studies explored the association between stressful distressing effects of emotions and mental representations that experiences, shame, and guilt considering them as negative state are generally associated with conflict ( Boldrini et  al., 2020). emotional experiences on one side or as lasting ae ff ctive personal Defense mechanisms are categorized and assessed on a continuum predisposition on the other side. Within the first perspective from adaptive to pathological. More adaptive defenses (e.g., shame and guilt are analyzed as state emotions that are elicited humor, altruism, sublimation, and suppression) usually maximize by specific and contextual social situations and that are assessed the awareness of ae ff ctive mental states, allowing an individual by exploring how the participant is feeling in the here and to adaptively modulate the expression and gratification of now (Cavalera et  al., 2017). As shame and guilt not only consist personal needs and desires (Boldrini et  al., 2020). Conversely, in transient emotional experiences, a second and integrative less adaptive or immature defenses (e.g., denial, acting out, view analyzed them in terms of lasting ae ff ctive predisposition projective identification, and splitting) may involve distortions using for example scenario-based measures (Tangney and Dearing, in the internal representations of self, others, or external reality, 2003). Within this last perspective, a lot of studies evidenced and keep potentially threatening ideas, feelings, memories, a relationship between shame and guilt proneness and wishes or fears out of one’s awareness (Maei et  ff al., 1995 ; psychopathological symptoms that can be  associated with Boldrini et  al., 2020). unresolved traumatic experiences (Tangney and Dearing, 2003; Emotional dysregulation related to unresolved shame and Vikan et  al., 2010; Vizin et  al., 2016). While in most of the guilt experiences can lead to the use of involuntary immature case the relationship between shame and psychological symptoms defenses (i.e., acting out, splitting, displacement, and was confirmed ( Rüsch et al., 2007; Schoenleber and Berenbaum, dissociation) that are commonly associated with less adaptive 2012), the relationship between guilt and symptoms severity is functioning (Prunas et  al., 2019). The tendency to experience characterized by more controversial results (Harder et  al., 1992; immature defense is characterized by disruptions between Tangney et  al., 1992; Averill et  al., 2002; Fergus et  al., 2010; the normally integrated systems of attention, awareness, Vizin et  al., 2016). Moreover, when the impact of shame and memory, and identity (Dalenberg et  al., 2012). There is guilt on Post-Traumatic Stress Disorder (PTSD) symptoms are evidence that negative emotional states, such as guilt and examined together, shame typically emerges as the strongest shame, may mediate this relationship between immature predictor (e.g., Street and Arias, 2001). Leskela et  al. (2002), defenses, such as peritraumatic dissociation and trait exploring PTSD in 107 former prisoners of war, found that dissociation (Barnow et al., 2011; Rugens and Terhune, 2013). shame-proneness but not guilt proneness was related to severity More specifically, the experience of guilt is a reliable predictor of psychological symptoms. Once the effects of shame were of immature defenses, which may function as a coping statistically removed, guilt showed a negative relationship with mechanism following trauma (Spiegel, 1986; Irwin, 1998). psychological symptoms. This suggests that shame rather than For example, considering dissociative responses Rugens and guilt is central to the pathognomonic outcome of relational Terhune (2013) found that those participants who had a stressful experiences. However, all these previous studies explored trait propensity toward dissociation reported a higher the role of shame and guilt proneness without analyzing the dissociation score immediately after exposure to guilt cues association between symptoms and state shame and guilt than after exposure to general negative cues and neutral specifically related to personal stressful events. cues. The present mechanism may lead to affect regulation, Besides shame and guilt proneness, state shame and state reducing the emotional impact of guilty feelings by creating guilt considered as negative emotional experiences can both psychological distance via strategies, such as depersonalization, be  related to very stressful psychopathological symptoms. derealization, intense absorption in selected stimuli, confusion Recent studies explored shame and guilt relations with about oneself, losing self-reference, and amnesia (e.g., Platt Frontiers in Psychology | www.frontiersin.org 2 May 2022 | Volume 13 | Article 832237 Cavalera et al. Defense Mechanisms, Shame, and Guilt and Freyd, 2015). In the same way, many years of studies the investigation of the relationship between shame and guilt on the association between shame, dissociative tendencies, activations, symptoms severity, and immature defenses, evaluating and abuse evidenced that immature defenses and shame are a mediation model. In line with these aims, specific hypotheses consistently related (Talbot et  al., 2004; Dorahy et  al., 2017; were: (1) State guilt and shame scores related to personal Khosravi, 2020); more specifically, Dorahy et al. (2017) found stressful events are positively correlated with psychopathological out that shame-evoking stimuli have the capacity to produce symptoms related to global severity index; (2) State guilt and heightened initial intrusions, and dissociation as a consequence shame scores related to personal stressful events are positively of this shame appears to be  a driver in the development of correlated with immature defenses; (3) Immature defenses more distressing intrusions. These findings add support to mediate the relationship between, respectively, state shame and the importance of exploring the role of state shame and state guilt with psychopathological symptoms. guilt and immature defenses related to psychological symptoms in a more broader perspective and not considering only MATERIALS AND METHODS dissociative defenses (Andrews et  al., 1989; Leskela et  al., 2002; Aakvaag et  al., 2014). Participants Participants at least 18 years of age were recruited through the Immature Defenses and main social networks related to Catholic University of Milan. Psychopathological Risk All the participants provided informed consent aer r ft eceiving Growing evidence confirmed the association between the use a complete description of the study and had the opportunity of primitive and dysfunctional defense mechanisms and the to ask questions before completing the self-report questionnaires psychopathological risk (Zanarini et  al., 2009; Calati et  al., via the Qualtrics online platform. No incentives were provided 2010; Marchesi et al., 2011). Studies in both clinical (Spinhoven to the participants. The present study was approved by the and Kooiman, 1997; Calati et al., 2010), and non-clinical samples ethics board of the Catholic University of Milan. In the course highlighted the link between immature defenses and psychological of the recruitment, a total of 140 participants were reached symptoms even for sub-clinical form of distress (Muris et  al., out to complete the study. When participants provided incomplete 2003; Cramer, 2006; Sarno et al., 2010). Spinhoven and Kooiman responses regarding the variables of interest data were excluded (1997) evidenced that compared to controls, anxiety and by the analysis. depressive disorder patients scored higher for the use of immature Because of missing data when completing the assessment, defense style. More recently, Prunas et  al. (2019) confirmed 50 subjects were excluded from the analysis. A possible the association between the use of primitive defenses and the explanation of such a high number of incomplete answers is psychopathological risk with a moderating role of gender that some of the participants probably thought they could showing that women obtained higher scores than men. In a take a break and resume the questionnaire later only to discover more recent study, immature defenses showed correlations with when they returned that they had to start over again. The insecure attachment in a non-clinical sample of adults (Prunas final group consisted of 90 participants (48.9% female). Mean et  al., 2019). Hyphantis (2010) evidenced that the use of age was 23.66 (SD = 2.14, range 19–28). immature defenses increased the variance explained of 19.2% related to global severity index scores. While adaptive defenses Measures showed negative correlations with GSI, maladaptive defenses Symptom Checklist-90 (SCL-90, Derogatis et  al., 1973) is were the major independent correlate of global severity index a self-administered questionnaire consisting of 90 items on (Hyphantis, 2010). the sensations experienced in the week prior to administration. Although defense mechanisms are oen dir ft ected against The questionnaire has a Likert scale from 0 (not at all) to threats to self-esteem to protect the self from the negative 4 (very much). There are 10 dimensions relating to clinical effect of disappointment ( Cramer, 2006), no study so far explored psychopathological symptoms, and it is possible to obtain the role of immature defenses in the relation between negative the Global Severity Index (GSI). For the purpose of the self-conscious emotions and symptoms severity. present study, only GSI was considered. The scale showed a good index of internal consistency and reliability with The Current Study values ranging from 0.73 (Rosen et  al., 2000) to 0.85 (Donini e c Th urrent study explored the link between unresolved negative et  al., 2020). self-conscious emotions, defenses, and psychopathology. As Response Evaluation Measure (REM-71, Prunas et  al., 2006) growing empirical evidence confirmed the close association is a self-report scale composed of 71 items that investigates 21 between defense style, unresolved negative emotions and mental defenses on a 9-step Likert scale 1 (strongly disagree) 9 (strongly health (Andrews et  al., 1989; Spinhoven and Kooiman, 1997; agree). There are two factors related to adaptive (composed by Bond and Perry, 2004; Prunas et  al., 2006), the aim of the 7 scales) and immature defense mechanisms (composed by 14 present study is to explore the relationship between state guilt scales). For the purpose of the present study, only immature and state shame activations related to personal stressful defense factor was considered. The Italian version showed a experiences and to evaluate their association with good internal consistency, with a value of 0.82 for the immature psychopathological symptoms. In particular, we  will focus on defenses and 0.72 for the mature defenses (Prunas et  al., 2019). Frontiers in Psychology | www.frontiersin.org 3 May 2022 | Volume 13 | Article 832237 Cavalera et al. Defense Mechanisms, Shame, and Guilt State shame and guilt scale-8 (SSGS-8, Cavalera et  al., RESULTS 2017) is a self-reported questionnaire consisting of 8 questions based on a Likert-type scale to 5 from 1 (disagree) to 5 Descriptive statistics, including demographic information, means, (very agree) that explore state guilt and shame. Examples standard deviations, and ranges for the considered outcomes of shame items are “I feel small,” “I feel worthless, powerless,” at T1 are reported in Table  1. while examples of guilt items are “I feel tension about In terms of years of education, the sample showed a rather something I  have done,” “I feel like apologizing, confessing.” high level as 33.3% reported having attended college while 45.6% SSGS-8 showed a good reliability for both the guilt (Cronbach reported having bachelor’s degree and 14.4% master’s degree. α = 0.84) and shame (Cronbach α = 0.81) factors (Cavalera More information related to other demographic measured and the et  al., 2018). descriptive statistics divided for male and females were provided in the supplementary material (Supplementary Tables S1, S2). Pearson and Spearman correlations between variables are Procedure reported in Table  2. All the correlations between variables Aer r ft eading and accepting the informed consent, participants were significant and were in the expected direction. The strongest completed an initial session of socio-demographic questions. correlations were between psychopathological symptoms and Next, an autobiographical emotional memory task in which the other variables of interests confirming the initial hypotheses. subjects were asked to report the most unpleasant experiences More specifically state guilt and shame scores related to personal they experienced was administered. They were given the following stressful events were positively correlated with psychopathological instructions: “Take a few minutes and think back to the three symptoms related to psychopathological symptoms and with most unpleasant events you  have ever experienced. For each immature defenses. of these three events, identify the worst scene and report it e p Th arallel mediation model was used to evaluate separately below. Write freely without worrying about mistakes. When the indirect effect of state shame and state guilt on finished, you  can do whatever you  want with this sheet. What psychopathological symptoms through the effect of immature you  write will not be  read by anyone.” Later, participants were defenses. Bootstrapped confidence intervals showed that both asked to complete the SGSS-8 in relation to each of the reported the associations between state shame and GSI and between stressful experiences. Aer ft that SCL-90 and REM-71 were state guilt and GSI were partially mediated by immature defenses. administered. At the end of the writing emotional task, e o Th verall model related to state guilt accounted for 46.33% participants were reported that a psychologist of the research of the variance in psychopathological symptoms scores and team was available for eventual psychological support. In the was significant F = 37.55 p < 0.0001 (Table  3; Figure  1). 2,87 event that the re-enactment elicits a high level of stress, the e o Th verall model related to state shame accounted for contact details of an adequately trained researcher were provided 40.57% of the variance in psychopathological symptoms scores at the end of the experiment. and was significant F = 29.69 p < 0.0001 (Table  4; Figure  1). 2,87 Considering the results obtained by the analyses, all the Statistical Analyses following hypotheses have been accepted: (1) State guilt and Statistical analyses were conducted using IBM SPSS, version shame scores related to personal stressful events are positively 22.0. The within-group Mahalanobis distance showed that correlated with psychopathological symptoms; (2) State guilt considering the variables of interest there were no multivariate and shame scores related to personal stressful events are outliers (Mahalanobis distance p < 0.001; Tabachnick et  al., positively correlated with immature defenses; (3) Immature 2007). Means and standard deviations were calculated for each defenses mediates the relationship between, respectively, state continuous variables measured in the study. Comparisons were shame and state guilt with psychopathological symptoms. made using Pearson correlation. As some of the data were not normally distributed (GSI and state shame scores), for correlations in which at least one of the variables was not DISCUSSION normally distributed Spearman was used instead of Pearson In the present, the role that state shame and state guilt activations analyses according to the distribution of the variables (Mishra et  al., 2019). related to stressful experience has on  psychopathological Finally, mediation models were tested using the SPSS macro PROCESS (Hayes, 2013). The indirect effects of, TABLE 1 | Participants characteristics. respectively, state shame, and state guilt on psychopathological symptoms through immature defenses were analyzed through Variables Range Mean SD two separated mediation models. Direct and indirect effects were estimated using Preacher and Hayes techniques with Age 19–28 23.66 2.14 5,000 bootstrap samples (Preacher and Hayes, 2004). Mediation State guilt 12–46 26.52 9.22 State shame 13–58 33.16 8.98 effects were further evaluated using bias-corrected Psychopathological symptoms 0.01–2.27 0.89 0.46 bootstrap  95% confidence intervals (CI). The effects were Immature defenses 8.64–17.71 12.40 2.21 considered statistically significant if the confidence intervals did not contain zero. N = 90. Frontiers in Psychology | www.frontiersin.org 4 May 2022 | Volume 13 | Article 832237 Cavalera et al. Defense Mechanisms, Shame, and Guilt symptoms through defense mechanism was analyzed. As the earlier literature suggest (Tracy and Robins 2006; Dorahy hypothesized, both state shame and state guilt were significantly et  al., 2017; Cavalera et  al., 2018) shame can be  related to correlated with psychopathological symptoms. This is consistent internalizing problems, interpersonal misunderstandings, with a large body of research that highlighted the dysfunctional depression, anxiety, and eating disorders. er Th efore, as confirmed role of these two self-conscious emotions (Cavalera et al., 2017, by the present data, unresolved shameful feelings related to 2018; Dorahy et  al., 2017; Cândea and Szentagotai-Tătar, 2018) stressful personal experiences can be related to poor psychological when they are related to unresolved experiences. A prolonged adjustment. It is possible that maladaptive role of state shame condition of maladaptive guilt related to previous transgressions on mental wellbeing may be particularly disruptive when personal or bad mistakes can imply disruptive consequences for mental level of frustration discomfort is high (Tangney et  al., 2014). health. Consistently with other data (Rugens and Terhune, One other crucial finding is that the effect of both state 2013; Taihara and Malik, 2016), the  present study evidenced shame and guilt activations on psychological distress is partially that feelings of hyper-responsibility  related to unresolved state mediated by immature defenses. More in detail we  proposed guilty are related to psychopathological distress. These can a model in which state shame and guilt activations elicited be expressed through very different psychopathological symptoms through an autobiographical emotional memory task influence that may be  related to the externalization of blame, anger, psychological distress through the negative effect of primitive hostility, or self-resentment usually related to maladaptive guilt defenses. Our model explains that a substantial proportion of (Taihara and Malik, 2016). psychological distress is related to shame and guilt activations As expected, state shame showed the strongest correlations and evidenced that immature defenses partially mediated this with GSI suggesting that the deep discomfort elicited by shame association. A possible explanation of the present mediation can have dramatic relations with psychological imbalances. As model is that both shame and guilt convey crucial information for personal identities that may be  hard to process. When these experiences are perceived as unsustainable, TABLE 2 | Correlation between study variables. they can be  related to a less integrated system of attention, working memory inefficiencies, and heightened cognitive Variables 1 2 3 4 intrusions (Dalenberg et al., 2012; Dorahy et al., 2017; Cavalera a, a, a, State guilt 1 0.33 ** 0.47 *** 0.24 * et  al., 2018). The use of immature defenses can be  an a, b, State shame 1 0.36 ** 0.21 * involuntary way to manage the effects of such disruptive a, Psychopathological 1 0.59 *** attentive consequences trying to express feelings of panic symptoms or urgency (f.e. through acting—out or projection) or trying Immature defenses 1 to reduce the psychological impact of such maladaptive N = 90. emotions (f.e. through dissociation or repression) by creating *p < 0.05; **p < 0.01; ***p < 0.001. psychological distance. The present model expands the results Spearman rho. Pearson r. of previous research (Rugens and Terhune, 2013; Dorahy TABLE 3 | Mediation model of the mediating role of immature defenses in the relationship between guilt and psychological distress. Variables Overall mode fit Significance of regression coefficient Outcome Predictor R R F B LLCI ULCI t Immature defenses Guilt 0.2463 0.0607 5.6845* 0.8262 0.1375 1.5148 2.3842* Psychopathological Guilt immature 0.6806 0.4633 37.5483*** 0.0185 0.0105 0.0265 4.5811*** symptoms defenses 0.0072 0.0048 0.0096 6.0008*** N = 90. *p < 0.05; ***p < 0.001. TABLE 4 | Mediation model of the mediating role of immature defenses in the relationship between shame and psychological distress. Variables Overall mode fit Significance of regression coefficient Outcome Predictor R R F B LLCI ULCI t Immature defenses Shame 0.2127 0.0453 4.1719* 0.7324 0.0198 1.4450 2.0425* Psychopathological Shame immature 0.6369 0.4057 29.6951*** 0.0140 0.0054 0.0226 3.2440** symptoms defenses 0.0077 0.0052 0.0102 6.1403*** N = 90. *p < 0.05; **p < 0.01; ***p < 0.001. Frontiers in Psychology | www.frontiersin.org 5 May 2022 | Volume 13 | Article 832237 Cavalera et al. Defense Mechanisms, Shame, and Guilt FIGURE 1 | Mediation model of the mediating role of immature defenses in the relationship between state-shame, state-guilt, and psychopathological symptoms. et  al., 2017) by highlighting the relationship between guilt CONCLUSION and shame and not only dissociation but also with other e c Th urrent study extends earlier research on psychological immature defense mechanisms. Since mature defenses are an indication not only of the severity of psychopathology, imbalances by looking at the potential maladaptive role of shame and guilt for mental health. Our findings provide evidence but also a good predictor of therapeutic alliance and treatment response (Bond and Perry, 2004), an accurate evaluation of for the role of shame and guilt on psychological symptoms considering these emotions from a situational perspective. Since the individual defense profile could be  useful for planning specific interventions during psychotherapy (e.g., interpretive most of the existing literature investigated psychological implications of personal proneness to shame and guilt, the vs. supportive interventions) in order to manage unresolved experiences of shame and guilt. present data oer ff key contributions related to shame and guilt in terms of state emotions. Limitations An important aspect is that data showed a partial mediation e Th current study is not without limitations. Firstly, participants of defense mechanisms suggesting that they accounts for some might have imprecisely reported how they retrospectively felt (but not for all) of the critical aspects related to the relationship in relationship with their personal experiences. In addition to between self-conscious emotions and psychological distress. It that, data could have been influenced by individual skill in get is possible that other variables mediate or moderate the involved into personal memory about the past. Although the relationship between these negative self-conscious emotions sample was not collected in a clinical setting, specific information and psychological distress. The level of frustration or personal regarding the presence of emotional problems was not collected. predisposition of internalizing/externalizing problems can Further, the order in which different measures were proposed be  interesting factors that can be  explored by future research may have had an effect on the results obtained. More specifically, (Taihara and Malik, 2016). the emotional memory task may have influenced the compilation The present findings provide critical implications for of the subsequent self-rating scale. As it was considered more psychotherapists and mental health workers. Managing complex, priority was given to the emotional memory task unresolved experiences related to shame and guilt may become which was therefore proposed as the first measure to be assigned. a key target in psychotherapy that could help patients break To encourage greater freedom in selecting past memories, recursive thoughts and maladaptive defensive strategies we  did not ask for specific information with respect to the (Houazene et  al., 2021). Specific efforts can be  addressed in type of event chosen. Therefore, participants had the opportunity understanding and accepting the reasons and the feelings to choose experiences with different levels of magnitude (i.e., underlying shameful and guilty experiences fostering a self- rape or failing an exam). Despite this aspect, the presence of compassionate attitude (Goss and Allan, 2010). This may the SSGS-8 allowed for the control of subjective emotional have important crucial consequences in the reduction of activation beyond the nature of the triggering event. psychological symptoms (Kelly et al., 2017). A specific attention Another limiting aspect is that the present study focused may be  also directed to the use of primitive defense specifically on state shame and guilt emotions and omitted to mechanisms. A deeper awareness of these involuntary strategies include additional emotional memory tasks triggering other may help the patients to notice and prevent the recursive negative emotional experiences. Future research may explore patterns highlighted by shame and guilt and deactivate their the role of state fear or rage on psychological imbalances. negative potential. Frontiers in Psychology | www.frontiersin.org 6 May 2022 | Volume 13 | Article 832237 Cavalera et al. Defense Mechanisms, Shame, and Guilt interpretation of data for the work. CC and OO finally DATA AVAILABILITY STATEMENT approved the version of the paper to be  published. All e Th raw data supporting the conclusions of this article will authors contributed to the article and approved the be  made available by the authors, without undue reservation. submitted version. ETHICS STATEMENT FUNDING e s Th tudies involving human participants were reviewed and Università Cattolica del Sacro Cuore contributed to the funding approved by Commissione Etica Università Cattolica del Sacro of this research project and its publication. Cuore di Milano. The patients/participants provided their written informed consent to participate in this study. SUPPLEMENTARY MATERIAL AUTHOR CONTRIBUTIONS e S Th upplementary Material for this article can be  found online CC, PA, OB, and OO made substantial contributions to the at: https://www.frontiersin.org/articles/10.3389/fpsyg.2022.832237/ conception or design of the work and to the analysis and full#supplementary-material REFERENCES Dalenberg, C. J., Brand, B. L., Gleaves, D. H., Dorahy, M. J., Loewenstein, R. J., Cardena, E., et al. (2012). Evaluation of the evidence for the trauma and Aakvaag, H. F., Thoresen, S., Wentzel-Larsen, T., Røysamb, E., and Dyb, G. fantasy models of dissociation. Psychol. Bull. 138, 550–588. doi: 10.1037/a0027447 (2014). Shame and guilt in the aer ft math of terror: the Utøya Island study. Derogatis, L. R., Lipman, R. S., and Covi, L. (1973). SCL-90: an J. Trauma. Stress. 27, 618–621. doi: 10.1002/jts.21957 outpatient psychiatric rating scale–preliminary report. Psychopharmacol. Bull. American Psychiatric Association (2013). 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Do Immature Defense Mechanisms Mediate the Relationship Between Shame, Guilt, and Psychopathological Symptoms?

Cavalera, Cesare; Andreani, Paolo; Baumgartner, Oliver; Oasi, Osmano
Frontiers in Psychology , Volume 13 – May 3, 2022
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ORIGINAL RESEARCH published: 03 May 2022 doi: 10.3389/fpsyg.2022.832237 Do Immature Defense Mechanisms Mediate the Relationship Between Shame, Guilt, and Psychopathological Symptoms? Cesare Cavalera *, Paolo Andreani , Oliver Baumgartner and Osmano Oasi Deparment of Psychology, Università Cattolica del Sacro Cuore, Milan, Italy When shame and guilt emotional experiences related to stressful events remain unresolved, they can be  related to psychological impairment and recursive thoughts. The present study aims to explore the association between state shame and state guilt related to past stressful experiences and psychopathological symptoms and evaluating a mediation role by immature defenses. A total of 90 participants (48.9% female; mean age 23.66) were considered in the present study to (a) investigate correlations between state guilt and shame scores related to personal stressful events and psychopathological symptoms Edited by: related to global severity index; (b) assess whether state guilt and shame scores related Leonardo Carlucci, University of Studies G. d’Annunzio to personal stressful events are positively correlated with immature defenses; (c) test Chieti and Pescara, Italy whether immature defenses mediates the relationship between, respectively, state shame Reviewed by: and state guilt with psychopathological symptoms. Significant correlations between state Diana Nechita, Babes-Bolyai University ̦ , Romania shame, state guilt, psychopathological symptoms, and immature defenses were found. Braj Bhushan, Higher activations on immature defenses partially mediated the relationship between Indian Institute of Technology Kanpur, psychopathological symptoms and state shame and state guilt, respectively. Past India experiences related to shame and guilt should be targeted by specific treatments that *Correspondence: Cesare Cavalera could help stop recursive maladaptive thoughts and empower more adaptive cesarem.cavalera@unicatt.it defensive strategies. Specialty section: Keywords: defense mechanism, shame, guilt, symptoms severity, self-conscious emotions This article was submitted to Psychology for Clinical Settings, a section of the journal Frontiers in Psychology INTRODUCTION Received: 09 December 2021 Traumatic and Psychopathological Implications of Shame and Accepted: 28 March 2022 Published: 03 May 2022 Guilt Trauma and memories of trauma can be  related to unresolved negative emotions with serious Citation: Cavalera C, Andreani P, consequences for quality of life and psychological balance (Vaillant, 1994; Dorahy et  al., 2017). Baumgartner O and Oasi O (2022) Guilt and shame are distinctive negative self-conscious emotions that, due to their nature, can Do Immature Defense Mechanisms be  related to traumatic experiences (American Psychiatric Association, 2013; Cavalera et  al., Mediate the Relationship Between 2018). Despite the fact they have many aspects in common (i.e., both originate from relevant Shame, Guilt, and transgression and failure of oneself), they differ in their trajectories. While guilt implies self- Psychopathological Symptoms? criticism of a specific personal action and it is associated with the damage it may have caused Front. Psychol. 13:832237. doi: 10.3389/fpsyg.2022.832237 to others, shame is the consequence of a negative self-evaluation (Tracy and Robins, 2006). Frontiers in Psychology | www.frontiersin.org 1 May 2022 | Volume 13 | Article 832237 Cavalera et al. Defense Mechanisms, Shame, and Guilt While feeling of shame are linked to a stable internal and impairing working memory process (Cavalera et  al., 2018) negative perception of the entire self (e.g., “I’m a bad person”), and with emotional dysregulation defined both in terms of guilt appears when people attribute an adverse outcome to overwhelming sensations and in terms of excessive deactivation internal, unstable, and controllable attributions (e.g., “I’ve made (Rugens and Terhune, 2013; Dorahy et al., 2017). Unresolved a bad mistake”). er Th efore, shame is associated with feelings state guilt or shame related to traumatic experiences may of inferiority and worthlessness for a defective self with the therefore cause panic, terror, or a sense of urgency (Breggin, consequent desire to hide or escape from a bad situation, 2015). On the other hand, excessive deactivation of emotions while guilt is associated with feelings of tension and remorse may cause depersonalization and derealization, or dissociative related to a wrong behavior (Tracy and Robins, 2006). As emotional numbing in such contexts that intensified emotions shame is intrinsic to social subordination, recursive shameful would be expected to occur (Pur, 2014). Rugens and Terhune experiences may be  related to thoughts that reflect a defective (2013) evidenced the role of guilt in augmenting the self. Maladaptive guilt may be also related to impairing thoughts relationship between dissociative tendencies and state of hyper-responsibility and self-criticism that occurs in dissociation. Similarly, State shame was also found to be  a interpersonal situation (Cavalera, 2020). Therefore, when shame significant predictor of dissociative symptoms in complex and guilt related to stressful event remain unresolved, they PTSD (Dorahy et  al., 2017). can readily be elicited in everyday situations causing psychological impairment and recursive thoughts (Irwin, 1998; Dorahy Shame, Guilt, and Immature Defenses et  al., 2017). Defense mechanisms play a central role in mitigating the Different studies explored the association between stressful distressing effects of emotions and mental representations that experiences, shame, and guilt considering them as negative state are generally associated with conflict ( Boldrini et  al., 2020). emotional experiences on one side or as lasting ae ff ctive personal Defense mechanisms are categorized and assessed on a continuum predisposition on the other side. Within the first perspective from adaptive to pathological. More adaptive defenses (e.g., shame and guilt are analyzed as state emotions that are elicited humor, altruism, sublimation, and suppression) usually maximize by specific and contextual social situations and that are assessed the awareness of ae ff ctive mental states, allowing an individual by exploring how the participant is feeling in the here and to adaptively modulate the expression and gratification of now (Cavalera et  al., 2017). As shame and guilt not only consist personal needs and desires (Boldrini et  al., 2020). Conversely, in transient emotional experiences, a second and integrative less adaptive or immature defenses (e.g., denial, acting out, view analyzed them in terms of lasting ae ff ctive predisposition projective identification, and splitting) may involve distortions using for example scenario-based measures (Tangney and Dearing, in the internal representations of self, others, or external reality, 2003). Within this last perspective, a lot of studies evidenced and keep potentially threatening ideas, feelings, memories, a relationship between shame and guilt proneness and wishes or fears out of one’s awareness (Maei et  ff al., 1995 ; psychopathological symptoms that can be  associated with Boldrini et  al., 2020). unresolved traumatic experiences (Tangney and Dearing, 2003; Emotional dysregulation related to unresolved shame and Vikan et  al., 2010; Vizin et  al., 2016). While in most of the guilt experiences can lead to the use of involuntary immature case the relationship between shame and psychological symptoms defenses (i.e., acting out, splitting, displacement, and was confirmed ( Rüsch et al., 2007; Schoenleber and Berenbaum, dissociation) that are commonly associated with less adaptive 2012), the relationship between guilt and symptoms severity is functioning (Prunas et  al., 2019). The tendency to experience characterized by more controversial results (Harder et  al., 1992; immature defense is characterized by disruptions between Tangney et  al., 1992; Averill et  al., 2002; Fergus et  al., 2010; the normally integrated systems of attention, awareness, Vizin et  al., 2016). Moreover, when the impact of shame and memory, and identity (Dalenberg et  al., 2012). There is guilt on Post-Traumatic Stress Disorder (PTSD) symptoms are evidence that negative emotional states, such as guilt and examined together, shame typically emerges as the strongest shame, may mediate this relationship between immature predictor (e.g., Street and Arias, 2001). Leskela et  al. (2002), defenses, such as peritraumatic dissociation and trait exploring PTSD in 107 former prisoners of war, found that dissociation (Barnow et al., 2011; Rugens and Terhune, 2013). shame-proneness but not guilt proneness was related to severity More specifically, the experience of guilt is a reliable predictor of psychological symptoms. Once the effects of shame were of immature defenses, which may function as a coping statistically removed, guilt showed a negative relationship with mechanism following trauma (Spiegel, 1986; Irwin, 1998). psychological symptoms. This suggests that shame rather than For example, considering dissociative responses Rugens and guilt is central to the pathognomonic outcome of relational Terhune (2013) found that those participants who had a stressful experiences. However, all these previous studies explored trait propensity toward dissociation reported a higher the role of shame and guilt proneness without analyzing the dissociation score immediately after exposure to guilt cues association between symptoms and state shame and guilt than after exposure to general negative cues and neutral specifically related to personal stressful events. cues. The present mechanism may lead to affect regulation, Besides shame and guilt proneness, state shame and state reducing the emotional impact of guilty feelings by creating guilt considered as negative emotional experiences can both psychological distance via strategies, such as depersonalization, be  related to very stressful psychopathological symptoms. derealization, intense absorption in selected stimuli, confusion Recent studies explored shame and guilt relations with about oneself, losing self-reference, and amnesia (e.g., Platt Frontiers in Psychology | www.frontiersin.org 2 May 2022 | Volume 13 | Article 832237 Cavalera et al. Defense Mechanisms, Shame, and Guilt and Freyd, 2015). In the same way, many years of studies the investigation of the relationship between shame and guilt on the association between shame, dissociative tendencies, activations, symptoms severity, and immature defenses, evaluating and abuse evidenced that immature defenses and shame are a mediation model. In line with these aims, specific hypotheses consistently related (Talbot et  al., 2004; Dorahy et  al., 2017; were: (1) State guilt and shame scores related to personal Khosravi, 2020); more specifically, Dorahy et al. (2017) found stressful events are positively correlated with psychopathological out that shame-evoking stimuli have the capacity to produce symptoms related to global severity index; (2) State guilt and heightened initial intrusions, and dissociation as a consequence shame scores related to personal stressful events are positively of this shame appears to be  a driver in the development of correlated with immature defenses; (3) Immature defenses more distressing intrusions. These findings add support to mediate the relationship between, respectively, state shame and the importance of exploring the role of state shame and state guilt with psychopathological symptoms. guilt and immature defenses related to psychological symptoms in a more broader perspective and not considering only MATERIALS AND METHODS dissociative defenses (Andrews et  al., 1989; Leskela et  al., 2002; Aakvaag et  al., 2014). Participants Participants at least 18 years of age were recruited through the Immature Defenses and main social networks related to Catholic University of Milan. Psychopathological Risk All the participants provided informed consent aer r ft eceiving Growing evidence confirmed the association between the use a complete description of the study and had the opportunity of primitive and dysfunctional defense mechanisms and the to ask questions before completing the self-report questionnaires psychopathological risk (Zanarini et  al., 2009; Calati et  al., via the Qualtrics online platform. No incentives were provided 2010; Marchesi et al., 2011). Studies in both clinical (Spinhoven to the participants. The present study was approved by the and Kooiman, 1997; Calati et al., 2010), and non-clinical samples ethics board of the Catholic University of Milan. In the course highlighted the link between immature defenses and psychological of the recruitment, a total of 140 participants were reached symptoms even for sub-clinical form of distress (Muris et  al., out to complete the study. When participants provided incomplete 2003; Cramer, 2006; Sarno et al., 2010). Spinhoven and Kooiman responses regarding the variables of interest data were excluded (1997) evidenced that compared to controls, anxiety and by the analysis. depressive disorder patients scored higher for the use of immature Because of missing data when completing the assessment, defense style. More recently, Prunas et  al. (2019) confirmed 50 subjects were excluded from the analysis. A possible the association between the use of primitive defenses and the explanation of such a high number of incomplete answers is psychopathological risk with a moderating role of gender that some of the participants probably thought they could showing that women obtained higher scores than men. In a take a break and resume the questionnaire later only to discover more recent study, immature defenses showed correlations with when they returned that they had to start over again. The insecure attachment in a non-clinical sample of adults (Prunas final group consisted of 90 participants (48.9% female). Mean et  al., 2019). Hyphantis (2010) evidenced that the use of age was 23.66 (SD = 2.14, range 19–28). immature defenses increased the variance explained of 19.2% related to global severity index scores. While adaptive defenses Measures showed negative correlations with GSI, maladaptive defenses Symptom Checklist-90 (SCL-90, Derogatis et  al., 1973) is were the major independent correlate of global severity index a self-administered questionnaire consisting of 90 items on (Hyphantis, 2010). the sensations experienced in the week prior to administration. Although defense mechanisms are oen dir ft ected against The questionnaire has a Likert scale from 0 (not at all) to threats to self-esteem to protect the self from the negative 4 (very much). There are 10 dimensions relating to clinical effect of disappointment ( Cramer, 2006), no study so far explored psychopathological symptoms, and it is possible to obtain the role of immature defenses in the relation between negative the Global Severity Index (GSI). For the purpose of the self-conscious emotions and symptoms severity. present study, only GSI was considered. The scale showed a good index of internal consistency and reliability with The Current Study values ranging from 0.73 (Rosen et  al., 2000) to 0.85 (Donini e c Th urrent study explored the link between unresolved negative et  al., 2020). self-conscious emotions, defenses, and psychopathology. As Response Evaluation Measure (REM-71, Prunas et  al., 2006) growing empirical evidence confirmed the close association is a self-report scale composed of 71 items that investigates 21 between defense style, unresolved negative emotions and mental defenses on a 9-step Likert scale 1 (strongly disagree) 9 (strongly health (Andrews et  al., 1989; Spinhoven and Kooiman, 1997; agree). There are two factors related to adaptive (composed by Bond and Perry, 2004; Prunas et  al., 2006), the aim of the 7 scales) and immature defense mechanisms (composed by 14 present study is to explore the relationship between state guilt scales). For the purpose of the present study, only immature and state shame activations related to personal stressful defense factor was considered. The Italian version showed a experiences and to evaluate their association with good internal consistency, with a value of 0.82 for the immature psychopathological symptoms. In particular, we  will focus on defenses and 0.72 for the mature defenses (Prunas et  al., 2019). Frontiers in Psychology | www.frontiersin.org 3 May 2022 | Volume 13 | Article 832237 Cavalera et al. Defense Mechanisms, Shame, and Guilt State shame and guilt scale-8 (SSGS-8, Cavalera et  al., RESULTS 2017) is a self-reported questionnaire consisting of 8 questions based on a Likert-type scale to 5 from 1 (disagree) to 5 Descriptive statistics, including demographic information, means, (very agree) that explore state guilt and shame. Examples standard deviations, and ranges for the considered outcomes of shame items are “I feel small,” “I feel worthless, powerless,” at T1 are reported in Table  1. while examples of guilt items are “I feel tension about In terms of years of education, the sample showed a rather something I  have done,” “I feel like apologizing, confessing.” high level as 33.3% reported having attended college while 45.6% SSGS-8 showed a good reliability for both the guilt (Cronbach reported having bachelor’s degree and 14.4% master’s degree. α = 0.84) and shame (Cronbach α = 0.81) factors (Cavalera More information related to other demographic measured and the et  al., 2018). descriptive statistics divided for male and females were provided in the supplementary material (Supplementary Tables S1, S2). Pearson and Spearman correlations between variables are Procedure reported in Table  2. All the correlations between variables Aer r ft eading and accepting the informed consent, participants were significant and were in the expected direction. The strongest completed an initial session of socio-demographic questions. correlations were between psychopathological symptoms and Next, an autobiographical emotional memory task in which the other variables of interests confirming the initial hypotheses. subjects were asked to report the most unpleasant experiences More specifically state guilt and shame scores related to personal they experienced was administered. They were given the following stressful events were positively correlated with psychopathological instructions: “Take a few minutes and think back to the three symptoms related to psychopathological symptoms and with most unpleasant events you  have ever experienced. For each immature defenses. of these three events, identify the worst scene and report it e p Th arallel mediation model was used to evaluate separately below. Write freely without worrying about mistakes. When the indirect effect of state shame and state guilt on finished, you  can do whatever you  want with this sheet. What psychopathological symptoms through the effect of immature you  write will not be  read by anyone.” Later, participants were defenses. Bootstrapped confidence intervals showed that both asked to complete the SGSS-8 in relation to each of the reported the associations between state shame and GSI and between stressful experiences. Aer ft that SCL-90 and REM-71 were state guilt and GSI were partially mediated by immature defenses. administered. At the end of the writing emotional task, e o Th verall model related to state guilt accounted for 46.33% participants were reported that a psychologist of the research of the variance in psychopathological symptoms scores and team was available for eventual psychological support. In the was significant F = 37.55 p < 0.0001 (Table  3; Figure  1). 2,87 event that the re-enactment elicits a high level of stress, the e o Th verall model related to state shame accounted for contact details of an adequately trained researcher were provided 40.57% of the variance in psychopathological symptoms scores at the end of the experiment. and was significant F = 29.69 p < 0.0001 (Table  4; Figure  1). 2,87 Considering the results obtained by the analyses, all the Statistical Analyses following hypotheses have been accepted: (1) State guilt and Statistical analyses were conducted using IBM SPSS, version shame scores related to personal stressful events are positively 22.0. The within-group Mahalanobis distance showed that correlated with psychopathological symptoms; (2) State guilt considering the variables of interest there were no multivariate and shame scores related to personal stressful events are outliers (Mahalanobis distance p < 0.001; Tabachnick et  al., positively correlated with immature defenses; (3) Immature 2007). Means and standard deviations were calculated for each defenses mediates the relationship between, respectively, state continuous variables measured in the study. Comparisons were shame and state guilt with psychopathological symptoms. made using Pearson correlation. As some of the data were not normally distributed (GSI and state shame scores), for correlations in which at least one of the variables was not DISCUSSION normally distributed Spearman was used instead of Pearson In the present, the role that state shame and state guilt activations analyses according to the distribution of the variables (Mishra et  al., 2019). related to stressful experience has on  psychopathological Finally, mediation models were tested using the SPSS macro PROCESS (Hayes, 2013). The indirect effects of, TABLE 1 | Participants characteristics. respectively, state shame, and state guilt on psychopathological symptoms through immature defenses were analyzed through Variables Range Mean SD two separated mediation models. Direct and indirect effects were estimated using Preacher and Hayes techniques with Age 19–28 23.66 2.14 5,000 bootstrap samples (Preacher and Hayes, 2004). Mediation State guilt 12–46 26.52 9.22 State shame 13–58 33.16 8.98 effects were further evaluated using bias-corrected Psychopathological symptoms 0.01–2.27 0.89 0.46 bootstrap  95% confidence intervals (CI). The effects were Immature defenses 8.64–17.71 12.40 2.21 considered statistically significant if the confidence intervals did not contain zero. N = 90. Frontiers in Psychology | www.frontiersin.org 4 May 2022 | Volume 13 | Article 832237 Cavalera et al. Defense Mechanisms, Shame, and Guilt symptoms through defense mechanism was analyzed. As the earlier literature suggest (Tracy and Robins 2006; Dorahy hypothesized, both state shame and state guilt were significantly et  al., 2017; Cavalera et  al., 2018) shame can be  related to correlated with psychopathological symptoms. This is consistent internalizing problems, interpersonal misunderstandings, with a large body of research that highlighted the dysfunctional depression, anxiety, and eating disorders. er Th efore, as confirmed role of these two self-conscious emotions (Cavalera et al., 2017, by the present data, unresolved shameful feelings related to 2018; Dorahy et  al., 2017; Cândea and Szentagotai-Tătar, 2018) stressful personal experiences can be related to poor psychological when they are related to unresolved experiences. A prolonged adjustment. It is possible that maladaptive role of state shame condition of maladaptive guilt related to previous transgressions on mental wellbeing may be particularly disruptive when personal or bad mistakes can imply disruptive consequences for mental level of frustration discomfort is high (Tangney et  al., 2014). health. Consistently with other data (Rugens and Terhune, One other crucial finding is that the effect of both state 2013; Taihara and Malik, 2016), the  present study evidenced shame and guilt activations on psychological distress is partially that feelings of hyper-responsibility  related to unresolved state mediated by immature defenses. More in detail we  proposed guilty are related to psychopathological distress. These can a model in which state shame and guilt activations elicited be expressed through very different psychopathological symptoms through an autobiographical emotional memory task influence that may be  related to the externalization of blame, anger, psychological distress through the negative effect of primitive hostility, or self-resentment usually related to maladaptive guilt defenses. Our model explains that a substantial proportion of (Taihara and Malik, 2016). psychological distress is related to shame and guilt activations As expected, state shame showed the strongest correlations and evidenced that immature defenses partially mediated this with GSI suggesting that the deep discomfort elicited by shame association. A possible explanation of the present mediation can have dramatic relations with psychological imbalances. As model is that both shame and guilt convey crucial information for personal identities that may be  hard to process. When these experiences are perceived as unsustainable, TABLE 2 | Correlation between study variables. they can be  related to a less integrated system of attention, working memory inefficiencies, and heightened cognitive Variables 1 2 3 4 intrusions (Dalenberg et al., 2012; Dorahy et al., 2017; Cavalera a, a, a, State guilt 1 0.33 ** 0.47 *** 0.24 * et  al., 2018). The use of immature defenses can be  an a, b, State shame 1 0.36 ** 0.21 * involuntary way to manage the effects of such disruptive a, Psychopathological 1 0.59 *** attentive consequences trying to express feelings of panic symptoms or urgency (f.e. through acting—out or projection) or trying Immature defenses 1 to reduce the psychological impact of such maladaptive N = 90. emotions (f.e. through dissociation or repression) by creating *p < 0.05; **p < 0.01; ***p < 0.001. psychological distance. The present model expands the results Spearman rho. Pearson r. of previous research (Rugens and Terhune, 2013; Dorahy TABLE 3 | Mediation model of the mediating role of immature defenses in the relationship between guilt and psychological distress. Variables Overall mode fit Significance of regression coefficient Outcome Predictor R R F B LLCI ULCI t Immature defenses Guilt 0.2463 0.0607 5.6845* 0.8262 0.1375 1.5148 2.3842* Psychopathological Guilt immature 0.6806 0.4633 37.5483*** 0.0185 0.0105 0.0265 4.5811*** symptoms defenses 0.0072 0.0048 0.0096 6.0008*** N = 90. *p < 0.05; ***p < 0.001. TABLE 4 | Mediation model of the mediating role of immature defenses in the relationship between shame and psychological distress. Variables Overall mode fit Significance of regression coefficient Outcome Predictor R R F B LLCI ULCI t Immature defenses Shame 0.2127 0.0453 4.1719* 0.7324 0.0198 1.4450 2.0425* Psychopathological Shame immature 0.6369 0.4057 29.6951*** 0.0140 0.0054 0.0226 3.2440** symptoms defenses 0.0077 0.0052 0.0102 6.1403*** N = 90. *p < 0.05; **p < 0.01; ***p < 0.001. Frontiers in Psychology | www.frontiersin.org 5 May 2022 | Volume 13 | Article 832237 Cavalera et al. Defense Mechanisms, Shame, and Guilt FIGURE 1 | Mediation model of the mediating role of immature defenses in the relationship between state-shame, state-guilt, and psychopathological symptoms. et  al., 2017) by highlighting the relationship between guilt CONCLUSION and shame and not only dissociation but also with other e c Th urrent study extends earlier research on psychological immature defense mechanisms. Since mature defenses are an indication not only of the severity of psychopathology, imbalances by looking at the potential maladaptive role of shame and guilt for mental health. Our findings provide evidence but also a good predictor of therapeutic alliance and treatment response (Bond and Perry, 2004), an accurate evaluation of for the role of shame and guilt on psychological symptoms considering these emotions from a situational perspective. Since the individual defense profile could be  useful for planning specific interventions during psychotherapy (e.g., interpretive most of the existing literature investigated psychological implications of personal proneness to shame and guilt, the vs. supportive interventions) in order to manage unresolved experiences of shame and guilt. present data oer ff key contributions related to shame and guilt in terms of state emotions. Limitations An important aspect is that data showed a partial mediation e Th current study is not without limitations. Firstly, participants of defense mechanisms suggesting that they accounts for some might have imprecisely reported how they retrospectively felt (but not for all) of the critical aspects related to the relationship in relationship with their personal experiences. In addition to between self-conscious emotions and psychological distress. It that, data could have been influenced by individual skill in get is possible that other variables mediate or moderate the involved into personal memory about the past. Although the relationship between these negative self-conscious emotions sample was not collected in a clinical setting, specific information and psychological distress. The level of frustration or personal regarding the presence of emotional problems was not collected. predisposition of internalizing/externalizing problems can Further, the order in which different measures were proposed be  interesting factors that can be  explored by future research may have had an effect on the results obtained. More specifically, (Taihara and Malik, 2016). the emotional memory task may have influenced the compilation The present findings provide critical implications for of the subsequent self-rating scale. As it was considered more psychotherapists and mental health workers. Managing complex, priority was given to the emotional memory task unresolved experiences related to shame and guilt may become which was therefore proposed as the first measure to be assigned. a key target in psychotherapy that could help patients break To encourage greater freedom in selecting past memories, recursive thoughts and maladaptive defensive strategies we  did not ask for specific information with respect to the (Houazene et  al., 2021). Specific efforts can be  addressed in type of event chosen. Therefore, participants had the opportunity understanding and accepting the reasons and the feelings to choose experiences with different levels of magnitude (i.e., underlying shameful and guilty experiences fostering a self- rape or failing an exam). Despite this aspect, the presence of compassionate attitude (Goss and Allan, 2010). This may the SSGS-8 allowed for the control of subjective emotional have important crucial consequences in the reduction of activation beyond the nature of the triggering event. psychological symptoms (Kelly et al., 2017). A specific attention Another limiting aspect is that the present study focused may be  also directed to the use of primitive defense specifically on state shame and guilt emotions and omitted to mechanisms. A deeper awareness of these involuntary strategies include additional emotional memory tasks triggering other may help the patients to notice and prevent the recursive negative emotional experiences. Future research may explore patterns highlighted by shame and guilt and deactivate their the role of state fear or rage on psychological imbalances. negative potential. Frontiers in Psychology | www.frontiersin.org 6 May 2022 | Volume 13 | Article 832237 Cavalera et al. Defense Mechanisms, Shame, and Guilt interpretation of data for the work. CC and OO finally DATA AVAILABILITY STATEMENT approved the version of the paper to be  published. All e Th raw data supporting the conclusions of this article will authors contributed to the article and approved the be  made available by the authors, without undue reservation. submitted version. ETHICS STATEMENT FUNDING e s Th tudies involving human participants were reviewed and Università Cattolica del Sacro Cuore contributed to the funding approved by Commissione Etica Università Cattolica del Sacro of this research project and its publication. Cuore di Milano. The patients/participants provided their written informed consent to participate in this study. SUPPLEMENTARY MATERIAL AUTHOR CONTRIBUTIONS e S Th upplementary Material for this article can be  found online CC, PA, OB, and OO made substantial contributions to the at: https://www.frontiersin.org/articles/10.3389/fpsyg.2022.832237/ conception or design of the work and to the analysis and full#supplementary-material REFERENCES Dalenberg, C. J., Brand, B. L., Gleaves, D. H., Dorahy, M. J., Loewenstein, R. J., Cardena, E., et al. (2012). Evaluation of the evidence for the trauma and Aakvaag, H. F., Thoresen, S., Wentzel-Larsen, T., Røysamb, E., and Dyb, G. fantasy models of dissociation. Psychol. Bull. 138, 550–588. doi: 10.1037/a0027447 (2014). Shame and guilt in the aer ft math of terror: the Utøya Island study. Derogatis, L. R., Lipman, R. S., and Covi, L. (1973). SCL-90: an J. Trauma. Stress. 27, 618–621. doi: 10.1002/jts.21957 outpatient psychiatric rating scale–preliminary report. Psychopharmacol. Bull. American Psychiatric Association (2013). 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Measuring shame and guilt by self-report questionnaires: a Conflict of Interest: The authors declare that the research was conducted in validation study. Psychiatry Res. 150, 313–325. doi: 10.1016/j.psychres. the absence of any commercial or financial relationships that could be  construed 2006.04.018 as a potential conflict of interest. Sarno, I., Madeddu, F., and Gratz, K. L. (2010). Self-injury, psychiatric symptoms, and defense mechanisms: findings in an Italian nonclinical sample. Eur. Publisher’s Note: All claims expressed in this article are solely those of the Psychiatry 25, 136–145. doi: 10.1016/j.eurpsy.2009.05.007 authors and do not necessarily represent those of their ali ffi ated organizations, Schoenleber, M., and Berenbaum, H. (2012). Shame regulation in personality or those of the publisher, the editors and the reviewers. Any product that may pathology. J. Abnorm. 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