Alleviation of Moral Disgust,Shame,and Guilt in Posttraumatic Stress Reactions

Abstract

Research suggests that moral disgust, shame, and guilt are present in posttraumatic psychopathology. However, it is unclear that these emotional states are responsive to empirically supported interventions for posttraumatic stress symptoms (PTSS). This study explored the relations among moral disgust, shame, guilt, and PTSS, and examined comprehensive distancing (CD) as a novel intervention for these emotional states in undergraduates with elevated PTSS. Participants were randomly assigned to use a CD or a cognitive challenge task in response to personalized scripts of a traumatic event. Both interventions were associated with decreases in disgust, moral disgust, shame, and guilt. Contrary to predictions, there were no significant differences between the exercises in the reduction of negative emotions. In addition, PTSS severity was correlated with trauma-related guilt as well as state guilt and shame, but not trait or state measures of disgust or moral disgust. This proof of concept project sets the stage for further research examining CD as an alternative or adjunctive intervention for posttraumatic stress reactions with strong features of moral disgust, shame, and guilt.

Keywords

disgust moral disgust guilt shame trauma acceptance and commitment therapy

In the current edition of the International Statistical Classification of Diseases and Related Health Problems (10th rev.; ICD-10), posttraumatic stress disorder (PTSD) is defined as a constellation of emotional, cognitive, and behavioral symptoms that occur in response to a traumatic event (World Health Organization, 1992). Contributions from theoretical, empirical, and biological research have informed the traditional conceptualization of PTSD as a disorder involving dysregulated fear responses (e.g., American Psychiatric Association [APA], 2000; Ehlers & Clark, 2000; Foa, Steketee, & Rothbaum, 1989; Shin et al., 2005). Existing empirically supported treatments for posttraumatic stress reactions have been developed around this body of PTSD literature, including cognitive and behavioral therapies (CBT; Cahill, Rothbaum, Resick, & Follette, 2009; Foa & Jaycox, 1999; Institute of Medicine, 2008) such as prolonged exposure (Foa & Chambless, 1978; Foa et al., 2005) and cognitive processing therapy (Resick, Nishith, Weaver, Astin, & Feuer, 2002; Resick & Schnicke, 1992). However, it is unclear to what extent these treatments are able to successfully reduce a wide range of emotional reactions to trauma (Orsillo & Batten, 2005).

This gap in the literature is becoming increasingly problematic, as mounting evidence suggests that responses to traumatic events can encompass a number of negative emotions other than fear, including general disgust, moral disgust, shame, and guilt. Relations between this constellation of negatively valenced evaluative emotions and posttraumatic stress symptoms (PTSS) have been outlined in the theoretical literature (e.g., Dalgleish & Power, 2004; Lee, Scragg, & Turner, 2001), evidenced in empirical investigations (e.g., Hathaway, Boals, & Banks, 2010; Shin et al., 1999), and referenced in the recently published Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013).

A growing literature broadly supports the role of disgust in the development of PTSS (Badour & Feldner, in press). Disgust is a basic emotion that evokes repulsion and avoidance for the evolutionary purpose of self-preservation (Rozin, Haidt, & McCauley, 2009; Woody & Teachman, 2000). In general, people with PTSS report experiencing disgust more frequently than do healthy individuals (Finucane, Dima, Ferreira, & Halvorsen, 2012). Furthermore, it is well established that individuals with PTSD resulting from a wide range of traumas show elevated disgust responsivity to laboratory-based trauma cues as compared with trauma-exposed individuals without PTSD (Pitman, Orr, Forgue, de Jong, & Claiborn, 1987; Shin et al., 1999). Several recent studies have also demonstrated that the trait of disgust propensity (how readily one feels disgusted; van Overveld, de Jong, Peters, Cavanagh, & Davey, 2006) and peritraumatic disgust (one’s disgust response during a trauma) predict PTSD symptom severity above and beyond the effects of fear (Badour, Bown, Adams, Bunaciu, & Feldner, 2012; Badour, Feldner, Blumenthal, & Knapp, 2013; Engelhard, Olatunji, & de Jong, 2011). Specifically, there is evidence that avoidance behaviors motivated by disgust sensitivity (the trait of how distressing one finds the experience of disgust; van Overveld et al., 2006) may moderate the relation between peritraumatic disgust and PTSS severity (Engelhard et al., 2011).

In addition to this research on how traits such as disgust propensity and sensitivity contribute to the development of PTSS, recent evidence has emerged supporting the relevance of state disgust reactivity in PTSS themselves. Badour, Feldner, Babson, Blumenthal, and Dutton (2013) demonstrated that PTSS severity predicted greater state disgust in response to trauma scripts in women who experienced sexual victimization, and Badour, Feldner, Blumenthal, and Knapp (2013) extended this work by showing that increased disgust reactivity in PTSS was significantly related to peritraumatic disgust in this population.

In addition to research establishing the relation between general disgust and PTSS, it appears that this connection may extend to moral disgust specifically, a dimension of disgust that is experienced toward people who violate boundaries of justice, social acceptability, or fairness (Rozin, Haidt, & Fincher, 2009; Tybur, Lieberman, & Griskevicius, 2009). Although the particular domain of moral disgust has not received as much attention as general disgust in the trauma literature to date, work in related areas suggests that there may be a meaningful relation between moral disgust and PTSS. Rachman and colleagues’ research on mental contamination provides evidence that a pervasive internal sense of “dirtiness” characterized by disgust may arise in the specific context of moral violation. The phenomenon of mental contamination was originally studied in individuals with obsessive-compulsive disorder (OCD; Rachman, 1994), and recent work has provided both qualitative (Coughtrey, Shafran, Lee, & Rachman, 2012) and empirical support (Coughtrey, Shafran, Knibbs, & Rachman, 2012; Cougle, Lee, Horowitz, Wolitzky-Taylor, & Telch, 2008) for the presence of mental contamination in obsessive-compulsive symptoms. Extensions of mental contamination research have also demonstrated its presence in the posttraumatic reactions of victims of sexual violation. The literature on mental contamination following sexual trauma has established a connection between interpersonal moral transgressions (i.e., unwanted sexual experiences) and disgust-related cognitions, emotions, and behaviors (Elliott & Radomsky, 2009; Fairbrother, Newth, & Rachman, 2005; Fairbrother & Rachman, 2004; Herba & Rachman, 2007; Rozin, Haidt, & McCauley, 2009), as well as PTSD symptoms specifically (Olatunji, Elwood, Williams, & Lohr, 2008). The prominent disgust element of mental contamination has been demonstrated among survivors of interpersonal traumas both via self-report (Badour et al., 2012; Petrak, Doyle, Williams, Buchan, & Forster, 1997) and in the laboratory (Badour et al., 2011; Rüsch et al., 2011). One recent study provided more explicit evidence for the role of disgust in mental contamination, finding increases in state disgust concurrent with feelings of internal dirtiness and urges to wash in response to trauma script-driven imagery (SDI) of past sexual assaults (Badour, Feldner, Babson, et al., 2013).

Although the precise nature of the relation between mental contamination and moral disgust has not yet been articulated, the occurrence of mental contamination—a phenomenon rooted in both disgust and moral evaluation (Badour, Ojserkis, McKay, & Feldner, in press; Elliott & Radomsky, 2009)—in response to traumatic events suggests that moral evaluative emotions may be relevant to posttraumatic stress reactions. The one study of which the authors are aware that has investigated the specific role of trait moral disgust in PTSS found that it consistently predicted posttraumatic avoidance as mediated by negative affect (Arocho, McKay, Adams, Lohr, & Maack, 2013). Taken together with the literature evidencing moral- and disgust-laden mental contamination responses to sexual assault, this work provides compelling evidence to examine the relation between trauma and moral disgust in greater depth.

To more thoroughly examine the role of moral disgust in PTSS, it is important to consider other negatively valenced, moral, evaluative emotions—namely, shame and guilt. Similar to moral disgust, shame and guilt are negatively valenced, moral, evaluative emotions that may be experienced in response to trauma. Shame is a form of characterological self-blame, whereas guilt typically occurs in response to a single, identifiable action (Andrews, 1998; Tangney, Stuewig, & Mashek, 2007; Tangney, Wagner, & Gramzow, 1992). Shame has been associated with disgust in the literature (Gilbert, 1998; Robinaugh & McNally, 2010; Rozin, Haidt, & McCauley, 2009), and has also been clearly related to PTSD symptomatology in experimental investigations (Olatunji, Babson, Smith, Feldner, & Connolly, 2009; Resick et al., 2008; Robinaugh & McNally, 2010; Shin et al., 1999; Sippel & Marshall, 2011). In fact, several studies have implicated shame not only as a reaction to trauma but also as a factor that affects the relation between trauma and PTSD symptom severity. Kimbrel et al. (2011) found that shame (as well as anger) mediated the relationship between combat exposure and PTSD symptom severity in veterans. Similarly, J. G. Beck et al. (2011) found the interaction between shame and severity of emotional abuse to predict PTSD symptoms in women experiencing intimate partner violence. Research suggests that guilt may also be present in PTSS resulting from a range of traumatic events (Hathaway et al., 2010; Jehu, 1989; Kubany, 1994; Kubany & Manke, 1995; Petrak et al., 1997). However, evidence for the specific role of guilt in posttraumatic reactions has been more equivocal than that of shame (Robinaugh & McNally, 2010).

These alternate presentations of PTSS based on moral disgust, shame, and guilt rather than fear have implications for treatment. Specifically, while exposure and cognitive therapies may include a full range of disgust-related stimuli, there is evidence that CBT may not be maximally effective for treating posttraumatic symptoms based on negatively valenced, moral, evaluative emotions related to disgust. The literature suggests that disgust-based reactivity is more resistant to extinction than is fear (Lee et al., 2001; Mason & Richardson, 2010; Olatunji, Forsyth, Cherian, 2007), perhaps due to the “law of contagion” that states, “once in contact [with a disgusting stimulus], always in contact” (Baeyens, Crombez, Van den Bergh, & Eelen, 1988; Rozin, Millman, & Nemeroff, 1986). In fact, both clinical and empirical studies have shown that exposure therapy, which is predicated on the principle of extinction, is not as effective in reducing disgust- and moral disgust–related symptoms as it is for emotional distress primarily based on fear (Gershuny, Baer, Radomsky, Wilson, & Jenike, 2003; McKay, 2006; Olatunji, Wolitzky-Taylor, Willems, Lohr, & Armstrong, 2009; Pitman et al., 1991; Resick & Schnicke, 1992). Research also suggests that disgust has a limited response to cognitive modification (Jones & Menzies, 1998; Sookman, Abramowitz, Calamari, Wilhelm, & McKay, 2005). Disgust may be less amenable to cognitive change because it is a “gut”-based emotion (Olatunji, Forsyth, Cherian, 2007) that possesses less accessible or identifiable cognitions than do other negative emotions such as fear, sadness, and anger (McKay & Tsao, 2005).

The literature suggesting that negatively valenced, moral, evaluative emotional reactivity is suboptimally responsive to both behavioral and cognitive interventions calls into question the efficacy of CBT for posttraumatic psychopathology with prominent moral disgust features. Considering the evidence for the role of disgust, moral disgust, shame, and guilt in posttraumatic reactions, it is crucial to examine potential adjuncts to existing treatments that may be tailored to address moral evaluative emotional reactivity following trauma.

One strategy that may be a promising alternative intervention for moral disgust, shame, and guilt in posttraumatic symptomatology is comprehensive distancing (CD). CD is a facet of acceptance and commitment therapy (ACT), in which one attempts to tolerate negative internal experiences (e.g., thoughts, emotions, memories) by engaging in specific strategies to uncouple evaluative mental events and associated emotional reactions, thus “distancing” oneself from them (Hayes, Kohlenberg, & Melancon, 1989; Zettle, 2005). In contrast to cognitive-behavioral interventions for PTSD, which require individuals to evaluate maladaptive thoughts and behaviors and increase openness to alternatives, CD promotes the acknowledgment and acceptance of negative mental events by assuming the stance of a detached, neutral observer who notices the occurrence of mental events but does not react to them (Orsillo & Batten, 2005; Zettle & Hayes, 1992). For instance, an effective use of the CD strategy may allow an individual to change her reaction to the mental event “I am dirty” from feeling self-disgust to telling herself, “I’m having a thought that I am dirty.” Experiencing internal events from the perspective of a non-judgmental observer allows an individual to see the self as a context for internal experiences rather than viewing oneself as his or her internal experiences. Regarding thoughts as “just thoughts” in this way decreases associated emotional distress (Hayes et al., 1989; Orsillo & Batten, 2005).

Numerous considerations suggest that CD may be apt for targeting moral disgust, shame, and guilt in posttraumatic stress reactions. First, the literature indicates that helping individuals to change the meaning of a traumatic event is a primary mechanism of action in the successful treatment of PTSD (Brewin, Dalgleish, & Joseph, 1996; Ehlers & Clark, 2000; Foa & Jaycox, 1999; Keane & Barlow, 2002; Resick, 2001; Resick et al., 2008). CD accomplishes this goal by shifting the internal evaluation of mental events from negative to neutral. Furthermore, research suggests that acceptance-based treatments are helpful in promoting emotional, behavioral, and neural changes in psychological disorders characterized by disgust, shame, and guilt that commonly co-occur with PTSD, including substance use disorders and borderline personality disorder (Gratz & Gunderson, 2006; Koenigsberg et al., 2009; C. M. Lang & Sharma-Patel, 2011; Luoma, Kohlenberg, Hayes, & Fletcher, 2012). Finally, two case studies have described the successful treatment of PTSD and comorbid diagnoses using ACT (Batten & Hayes, 2005; Orsillo & Batten, 2005). Based on this preliminary support for the use of ACT in treating posttraumatic reactions, a randomized clinical trial is currently underway examining ACT as an intervention for veterans with PTSD (A. J. Lang et al., 2012).

Taken as a whole, the literature shows that moral disgust, shame, and guilt may contribute to posttraumatic reactions at both the trait and state levels, and suggests that the ACT-informed technique of CD may be well suited to target symptoms characterized by this type of emotional reactivity. The existing body of research has set the stage for the current study: a proof of concept project examining the efficacy of a brief CD intervention for reducing self-reported negatively valenced, moral, evaluative emotions (moral disgust, shame, and guilt) in response to ideographic, laboratory-based trauma scripts in a sample of individuals with elevated PTSS. CD was compared with a parallel cognitive challenge exercise (“challenging cognitions” [CC]), which was chosen based on several theoretical and methodological considerations. First, CC serves as a clinically relevant comparison condition because cognitive flexibility and restructuring are components of many CBT interventions for PTSD. Cognitive interventions from which exposure components have been removed have also been shown to be efficacious treatments for PTSD in their own right (e.g., Resick et al., 2008). Furthermore, the procedures of delivering CC (e.g., duration, examples used) are similar to CD, yet the putative mechanism of action is distinct, a combination that allows for maximal internal validity in the comparison between these interventions.

It was hypothesized that CD would decrease self-reported state moral disgust, shame, and guilt more than the CC exercise. The current study also aimed to replicate previous relations between disgust, moral disgust, shame, and guilt, and PTSS severity at both state and trait levels. It was predicted that trait measures of disgust, moral disgust, shame, and guilt, as well as state levels of these emotions reported during the experiment, would be positively correlated with PTSS severity. To our knowledge, this study is the first to systematically examine an acceptance-based technique specifically for negatively valenced, moral, evaluative emotions in people with high levels of PTSS, and the second to investigate the efficacy of acceptance-based strategies in posttraumatic stress reactions using an experimental design.

Method

Participants

Undergraduate students (N = 445) were screened for participation in this study from the research subject pools at Fordham University (n = 248) and the University of Arkansas (n = 197). A portion of those screened was invited to participate in the study (for details on this process, see “Callback criteria”). A total of 55 participants completed the study. However, 10 of these individuals were excluded from data analyses, as they did not meet the callback criteria upon clarification beyond self-report (n = 5 at Fordham, n = 5 at Arkansas). Thus, the final sample included 45 participants.

Measures

Screening measures

Self-report questionnaires administered as screening measures are listed below.

Moral Disgust Scale (MDS)

The MDS is a 27-item self-report measure that asks respondents to rate a series of morally disgusting scenarios on a 5-point Likert-type scale from not at all disgusting to extremely disgusting. The MDS has demonstrated excellent internal consistency (Cronbach’s α = .90), as well as convergent and discriminant validity with measures of all four domains of disgust, scrupulosity, and anxiety sensitivity (Arocho et al., 2013).

Three Domain Disgust Scale (TDDS)

The TDDS is a 21-item self-report measure that assesses disgust sensitivity with respect to three evolutionarily based domains of disgust: pathogens, sexuality, and morality. The TDDS demonstrates good internal consistency (Cronbach’s α = .83-.89). In addition, each of the three factors of the TDDS has demonstrated distinct convergent and discriminant validity with various measures of psychopathology and personality traits (Tybur et al., 2009).

Positive and Negative Affect Schedule (PANAS)

The PANAS is a 20-item self-report measure consisting of two 10-item scales that measure positive and negative affect. The internal consistency of the PANAS is high (Cronbach’s α = .86-.90 for positive affect and Cronbach’s α = .84-.87 for negative affect), and test–retest reliability is moderate (r = .68 for positive affect; r = .71 for negative affect). The PANAS has also been shown to have acceptable convergent and discriminant validity with measures of state depression, anxiety, and general psychological distress (Watson, Clark, & Tellegen, 1988).

Test of Self-Conscious Affect–3 (TOSCA-3)

The TOSCA-3 (Tangney, Dearing, Wagner, & Gramzow, 2000) is a 16-item self-report measure that assesses affective, cognitive, and behavioral features associated with shame and guilt in scenarios commonly experienced by college students. Although the TOSCA-3 includes six subscales, only the Shame and Guilt scales were analyzed in this study. The TOSCA-3_shame demonstrates good internal consistency (Cronbach’s α = .88-.76) and the TOSCA-3_guilt evidences satisfactory internal consistency (Cronbach’s α = .57-.83; Rüsch et al., 2007; Tangney et al., 2000). The TOSCA-3 showed good convergent validity with the Personal Feelings Questionnaire (PFQ-2) for the Shame scale (r = .70), but minimal convergent validity for the Guilt scale (r = .34; Rüsch et al., 2007) in a healthy sample. The TOSCA-3 demonstrates good convergent validity with measures of trait anxiety, experiential avoidance, and general psychopathology (r = .34-.50 for Shame scale; r = .30-.39 for Guilt scale) in women with borderline personality disorder (Rüsch et al., 2007).

Life Events Checklist (LEC)

The LEC (Blake et al., 1995) is a 17-item self-report questionnaire that screens for a variety of potentially traumatic events. For each item, respondents indicate whether they experienced the event themselves, witnessed the event, learned about the event, are not sure if the event applies to them, or do not believe the event applies to them. The LEC has acceptable test–retest stability (1-week interval; measure dichotomized into “happened to me” vs. all other response categories): κ = .84-.37 (Gray, Litz, Hsu, & Lombardo, 2004). In addition, the LEC possesses strong convergent validity with other measures of trauma-related psychopathology (Gray et al., 2004). Although discriminant validity has only been assessed in the Korean version of the LEC, it has been shown to be acceptable (Bae, Kim, Koh, Kim, & Park, 2008).

For the purposes of operationalization in this study, the following question was appended to the LEC: “The events listed below correspond to items 1-17 on this questionnaire. If any of these events happened to you, please select the number of the ONE event (only one) that CAUSES YOU THE MOST DISTRESS.”

PTSD Checklist, Civilian Version (PCL-C)

The PCL-C (Weathers, Litz, Herman, Huska, & Keane, 1993) is a 17-item self-report measure assessing the severity of Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev; DSM-IV-TR; APA, 2000) PTSD symptoms in relation to “stressful experiences.” The PCL-C has demonstrated excellent internal consistency (Cronbach’s α = .85-.94) as well as test–retest reliability (r = .88-.92; Ruggiero, Del Ben, Scotti, & Rabalais, 2003). Finally, the PCL-C shows good convergent and discriminant validity with measures of PTSD symptomatology and general psychological distress (Ruggiero et al., 2003).

Impact of Event Scale, Revised (IES-R)

The IES-R (Weiss & Marmar, 1997) is a 22-item self-report measure that assesses DSM-IV-TR symptoms of PTSD experienced in the past week. The scale has high internal consistency (Cronbach’s α = .96) and convergent validity with the PCL (r = .84; Creamer, Bell, & Failla, 2003).

Posttraumatic Cognitions Inventory (PTCI)

The PTCI (Foa, Ehlers, Clark, Tolin, & Orsillo, 1999) is a 36-item self-report questionnaire that measures posttraumatic cognitions via three subscales: Negative Cognitions About Self, Negative Cognitions About the World, and Self-Blame. The PTCI has high internal consistency for both the total score and subscales (Cronbach’s α = .86-.97) as well as high test–retest reliability for a 1-week interval (ρ = .74-.89; Foa et al., 1999). The PTCI shows good convergent and discriminant validity, correlating moderately to strongly with measures of PTSD, depression, and anxiety, and distinguishing well between traumatized individuals with and without PTSD.

Trauma-Related Guilt Inventory (TRGI)

The TRGI is a 32-item self-report measure that assesses guilt specifically related to a traumatic event via three scales, all of which demonstrate high internal consistency: Global Guilt (Cronbach’s α = .90), Distress (Cronbach’s α = .86), and Guilt Cognitions (Cronbach’s α = .86). The TRGI has demonstrated good test–retest reliability in a sample of college students with histories of trauma (r = .73-86; Kubany et al., 1996). The TRGI has been shown to have adequate convergent and discriminant validity with measures of PTSD symptoms, guilt, and depression in samples of individuals with histories of a variety of traumatic events (Kubany et al., 1996).

Experimental measures

Questionnaires administered as a part of laboratory procedures are listed below.

Visual Analogue Scales (VAS)

VAS measures were constructed by the author for the purposes of the current study. Horizontal lines 15 cm in length each displayed a scale ranging from 0 to 100 with anchors at 0 (“not at all”) and 100 (“extremely”). Separate scales were provided for each of the following emotions: disgust, moral disgust, anxiety, guilt, shame, anger, sadness, and happiness. Participants were instructed to indicate how much they felt each emotion in the current moment by placing a vertical tick mark perpendicular to the scale. Identical VAS measures were administered before and after the experimental procedure. Percentages were calculated for VAS ratings (e.g., a mark placed at 12 of 15 cm on the scale was coded as 0.80).

Manipulation check forms

The authors developed two brief forms to assess the success of the experimental manipulation. The manipulation check prior to the experimental procedure (Manipulation Check A) assessed participants’ comprehension of their assigned thought strategies by asking them to provide a brief statement summarizing the technique. For Manipulation Check A, participants’ comprehension of assigned interventions was evaluated by experimenters, who used clinical judgment to match the participants’ summary of their assigned technique to the “take-away” points of the strategy previously delivered. The manipulation check after the experimental procedure (Manipulation Check B) assessed the extent to which participants felt that they were able to engage in their assigned thought strategy (options: “definitely used,” “used somewhat,” and “did not use”), and to briefly detail the ways in which they used their strategies in reaction to thoughts about their traumas.

Treatment history form

The experimenter developed a one-page questionnaire assessing previous psychotherapeutic and pharmacological treatment, including if, when, and for how long treatment was received; modality of psychological treatment; type and dosage of pharmacological treatment; and reason(s) for treatment.

Procedures

This study was approved by the Institutional Review Boards of Fordham University and the University of Arkansas. A schematic of the procedures for this study is depicted in Figure 1.

Figure 1.

Sequence of study procedures.

Screening procedures

Undergraduate students above the age of 18 who were enrolled in introductory psychology courses at Fordham University and University of Arkansas accessed screening measures online via the secure Sona Systems Ltd. Psychology Research Participation System and the Experimetrix System, respectively. After reading and electronically signing the informed consent form for the study screening, participants completed a battery of self-report questionnaires (see Figure 1).

Callback criteria

Individuals were invited to participate in the study based on the following criteria: (a) a score in the upper quartile on the PCL-C (i.e., those with the most severe PTSS; total score ≥ 40) and (b) endorsement of items fulfilling Criterion A of the DSM-IV-TR PTSD diagnosis. To assess callback criterion (a), quartiles for PCL-C scores were calculated using z score statistics in a sample of undergraduates at Fordham University (obtained separately from the present study; n = 237) and a community sample (n = 187). In both groups, the cutoff score for the upper quartile of data fell between 39.00 and 40.44 (Weiner, 2012). For the current study, a conservative cutoff of total PCL-C score ≥ 40.00 was selected to indicate “significant” PTSD symptom severity.

To assess callback criterion (b), additional questions developed by the experimental team were appended to the LEC to ascertain whether participants endorsing traumatic experiences fulfilled DSM-IV-TR Criterion A for their reported trauma (APA, 2000). To be eligible for the study, participants needed to endorse at least one of the questions 1 to 4 below (yes/no; DSM-IV-TR Criterion A1), as well as at least one of the questions 5 to 7 below (yes/no; DSM-IV-TR Criterion A2). Questions used to assess Criterion A are listed below:

During this traumatic event (the one that causes you the most distress, as indicated above)

Were you concerned that you or someone else might be physically injured?

Were you or someone else actually physically injured?

Did you think your life or someone else’s life was in danger?

Did you experience threat to your physical integrity (e.g., did you feel physically violated)?

Did you feel terrified?

Did you feel helpless?

Did you feel horrified?

The use of a subclinical undergraduate sample is consistent with evidence that PTSS exist along a continuum rather than as a dichotomous syndrome (Ruscio, Ruscio, & Keane, 2002), and that individuals do not need to meet full PTSD criteria to benefit from ACT-based strategies (Orsillo & Batten, 2005). Furthermore, data show that subthreshold and partial PTSD are more prevalent than the “full” disorder, yet are associated with similar impairment, comorbidity, and suicidality (Marshall et al., 2001; Zlotnick, Franklin, & Zimmerman, 2002).

Laboratory procedures

Individuals scoring in the upper quartile of the PCL-C and endorsing DSM-IV-TR Criterion A were invited to participate in a single laboratory session. Study experimenters were graduate students in the doctoral training programs at Fordham University (R.O. and J.A.) and the University of Arkansas (C.L.B. and C.D.). Participants who gave their informed consent on the day of study participation were randomly assigned to one of two conditions—a “comprehensive distancing” (CD) exercise (experimental condition) or a “challenging cognitions” (CC) exercise (comparison condition)—based on computer-generated randomization lists at each site.

Experimenters guided participants through (a) an introductory lesson, (b) a practice session, and (c) the experimental session (trauma-related exercise) of their thought strategies (see Figure 1). These exercises were modeled after the work of colleagues with a similar sample of Fordham students (Pilecki & McKay, 2012).

Personalized trauma scripts

At the beginning of each experimental session, subjects generated personalized trauma scripts. Specifically, they were asked to provide a brief (one-page) written account of the past traumatic event that they indicated was most distressing in the screening survey, with instructions to include as many details as possible about thoughts and sensory experiences (e.g., sights, smells, sounds) associated with the event. After writing this script, participants completed emotion ratings on the VAS.

Introductory lesson

Experimenters guided all participants through an introductory lesson for their assigned strategies. The introductory lesson served to initially familiarize participants with the principles of their assigned thought exercises and to give participants the opportunity to ask questions about their assigned techniques.

CD group

Participants randomly assigned to this group were given a description of the CD technique. This description was modeled from texts on ACT, the therapeutic tradition from which the exercise was derived (Hayes et al., 1989; Luoma & Hayes, 2008). Examples used to illustrate the CD technique to participants were developed by the study investigator. The experimenter read from a script explaining the concept behind the exercise:

This is an exercise that involves changing the way we think. Often times, when we have a thought, we automatically experience our world as though this thought is true. This is called “buying” thoughts. For example, I might have the thought, “I am a bad person,” and then feel as if it is true—that I am really a bad person. In reaction to this experience, I may search for additional thoughts, memories, or experiences that support this thought. For instance, I may remember a recent argument with a friend and think, “I said those angry things to my friend during our argument because I am a bad person.” However, sometimes it is useful to try a different strategy: being aware of our thoughts simply as thoughts. In this strategy, we look at the world and are aware that we are having thoughts, without experiencing them as the truth about the world. An example of using this strategy would be having the thought, “I am a bad person,” and then saying to myself, “I’m having that thought again that I’m a bad person.” Do you notice how in this example I acknowledged my thought, but I did not “buy” into it?

CC group

Participants randomly assigned to this group were given a description of the CC technique. This description was modeled from a text on cognitive therapy, the therapeutic tradition from which it was derived (J. S. Beck, 1995). Examples used to illustrate the CC technique to participants were developed by the study investigator. The experimenter read from a script explaining the concept behind the exercise:

This is an exercise that involves challenging the way we think. We are constantly having thoughts that pop in and out of our heads that comment on or evaluate what is going on in our worlds. Often times we do not stop and think about these “automatic thoughts”—we just accept them as the truth. The problem is that sometimes our thoughts are influenced by our preexisting attitudes about ourselves, the world, and the future. When this happens, our thoughts, and therefore our feelings about an event, can become distorted and no longer reflect reality. When we get stuck in an upsetting thought pattern, it can be helpful to take a step back and ask ourselves, “Is this really what is happening, or could this just be my biased interpretation of the situation?” When we challenge our automatic thoughts in this way, we often find that things are not actually as bad as they seem. For example, I might have the thought, “I am a bad person,” and then feel as if it is true—that I am really a bad person. In reaction to this experience, I may search for additional thoughts, memories, or experiences that support this thought. For instance, I may remember a recent argument with a friend and think, “I said those angry things to my friend during our argument because I am a bad person.” However, I could also think of the ways in which I have been a good friend to this same person, and this would contradict my thought that I am a bad person. Do you see how I used facts about reality to objectively evaluate whether or not my automatic thought was true?

Practice session

All participants practiced their assigned thought strategy prior to the experimental session. Participants were presented with the following scenario: “Your computer crashes just as you are finishing up a 10 page essay and you have to start over” (Pilecki & McKay, 2012). Participants were asked to imagine how they would feel in the computer crash scenario as vividly as possible, including thoughts, feelings, sights, sounds, and smells. Participants were then guided through an exercise in their assigned strategy (see below for scripts of each technique). All participants had the opportunity to ask questions about their assigned strategies. Finally, participants completed Manipulation Check A.

CD group

The experimenter read from a script guiding the participant through the practice session:

Now I’d like you to close your eyes, and imagine you are standing by a stream with leaves floating by. Imagine placing each new thought that arises about the scenario onto the leaves that are floating by down the stream in front of you. You see your thoughts etched on a leaf. You are simply an observer. Just as the leaves floating down the stream come and go, so do your thoughts. Remember these are just thoughts. They do not dictate your emotions.

The experimenter was able to draw from a bank of standardized follow-up questions to assist participants with the exercise:

Are you aware of the thoughts you’re having right now?

Are you able to see them simply as thoughts?

Can you see those thoughts floating past you in the stream? Do you see how they come and go?

Can you see yourself as that neutral observer, watching yourself having these thoughts?

CC group

The experimenter read from a script guiding the participant through the practice session:

Now identify what your automatic thoughts are about this situation. Consider the facts of reality surrounding this situation. Do the facts support your thoughts?

The experimenter was able to draw from a bank of several standardized follow-up questions to assist participants with the exercise:

Can you identify the automatic thoughts you are having right now?

What is the evidence for that thought being true?

What are some alternative possibilities to this automatic thought?

Experimental session

Participants were reminded of their assigned strategies, and then were asked to read their trauma scripts to themselves one time. After reading their written accounts of their traumatic events, participants were instructed to utilize their assigned strategies to respond to thoughts provoked by this reflection on their past traumatic experiences. Scripts for thought exercises and follow-up questions for the experimental session were identical to those described above for the practice session. Afterward, participants were asked to complete Manipulation Check Form B and to repeat the VAS.

Wrap-up

Following all study exercises, participants completed the treatment history form. They were then offered the opportunity to engage in a guided progressive muscle relaxation exercise (51% chose to participate; 49% declined). Finally, participants were debriefed, thanked, and compensated for their time. Participants were provided with the contact information for the study investigator and the university counseling center, and encouraged to call in the case that they experienced distress following the experimental procedures.

Compensation

All participants screened for participation in this study were compensated with one research credit for their introductory psychology course. At Fordham, study participants who came into the laboratory were given two options for compensation: two movie ticket vouchers to Regal Cinemas (approximately US$20.00 value) or one additional research credit for their introductory psychology course. Due to differing availability of movie theaters in the area, all study participants who came into the laboratory at the University of Arkansas were compensated with an additional research credit.

Overview of Analyses

An a priori power analysis was conducted using G*Power computerized software (Erdfelder, Faul, & Buchner, 1996) and was based on the following assumptions: α = .05, β = .2, Cohen’s d = 0.5. Effect size was estimated from previous literature on effect sizes for ACT-based interventions (Brown et al., 2011; Forman, Herbert, Moitra, Yeomans, & Geller, 2007) and disgust (Olatunji & Deacon, 2008). The power analysis revealed that a sample size of n = 24 was necessary to achieve the desired power for this study.

All analyses in this manuscript were run with SPSS Statistics software, version 19.0. Chi-square tests compared sample characteristics between the Fordham and Arkansas sites for gender, race, ethnicity, and trauma types. Independent-samples t tests compared participant age, as well as scores on screening self-report measures, across the Fordham and Arkansas sites. To test the hypothesis that CD would be associated with decreased self-reported disgust, moral disgust, shame, and guilt more than the CC exercise, repeated-measures general linear modeling (GLM) evaluated changes in participants’ emotional states (as measured by VAS) in response to self-generated trauma scripts before and after experimental interventions, both in general and specifically comparing the CD and CC groups. Because Pearson’s correlations did not reveal that VAS scores were significantly related to age, gender, prior treatment, experimenter, PANAS scores, or PCL-C scores, these factors were not included as covariates in the GLM analyses. In addition, zero-order Pearson’s correlations examined relationships between disgust, moral disgust, shame, and guilt (as measured by the TDDS, MDS, TOSCA-3, and TRGI, respectively, at the trait level, and VAS ratings at the state level) and PTSS (as measured by the PCL-C, IES-R, and PTCI).

Results

Sample Characteristics

The 45 participants in this study were 21.07 years old on average (SD = 4.40). The sample was 78% female, and self-identified with the following racial/ethnic backgrounds: 58% Caucasian/non-Hispanic, 24% Hispanic, 9% Black, 4% Asian, 11% “Other race,” and 2% “more than one race.” Of these participants, 44% reported experiencing a sexual trauma, 31% reported experiencing a violent trauma (physical assault or threat of physical violence), 11% reported experiencing the sudden loss of a loved one, 9% reported experiencing environmental dangers (fires, natural disasters), and 4% reported experiencing traumatic accidents.

Regarding treatment history, 64.4% of study participants reported having received psychotherapy in their lifetimes, 17 of whom (37.8% of sample) cited the trauma as a reason for seeking therapy. Eight participants (17.8% of sample) reported currently being enrolled in therapy at the time of the study. Twelve (26.7%) study participants reported ever being prescribed a psychotropic medication (specifically, antidepressants or benzodiazepines), 10 (22.2% of sample) of whom cited the trauma as a reason for the psychopharmacological treatment. Six participants (13.3% of sample) reported taking psychotropic medications at the time of the study.

Statistical analyses confirmed the comparability of participant characteristics between the Fordham and Arkansas sites. Specifically, chi-square tests found no significant differences between sites for participant gender, race, ethnicity, or distribution of the types of traumas reported. An independent-samples t test showed that Fordham participants were significantly older (M_age = 22.46, SD = 5.37) than those at Arkansas (M_age = 19.48, SD = 2.14); t(31) = −2.51, p = .02; homogeneity of variance not assumed, F = 18.99, p < .001. However, Pearson’s correlations did not reveal a significant relationship between age and outcome variables for this study (changes in VAS ratings from pre- to postintervention). No significant differences were found between sites for scores on screening questionnaires. In addition to this comparability of samples across sites, repeated-measures GLM analyses showed that neither the study experimenter nor participants’ previous treatment experience significantly affected outcome measures.

Effects of Interventions on Disgust, Moral Disgust, Shame, and Guilt

Repeated-measures GLM analyses (n = 45) showed a decrease in moral disgust, shame, and guilt (along with decreases in disgust, anxiety, sadness, and anger, and an increase in happiness) from pre- to postintervention across both conditions (p < .01, $η_{p}^{2}$ ranging from .18 to .54; see Table 1). Contrary to predictions, there were no significant differences between CD and CC in the extent to which they reduced negative emotions, including moral disgust, shame, and guilt, in response to personalized trauma scripts (see Figure 2). Including trauma type (interpersonal vs. non-interpersonal) as an additional between-subjects factor in these analyses did not show significant differences between CD and CC in reducing negative emotions following the personalized trauma scripts (p > .39 for all emotions measured). In these analyses, interpersonal trauma was defined as unwanted sexual experiences, physical abuse, violence, threats to physical safety from another person, and combat.

Table 1.

Results of Repeated-Measures General Linear Modeling for Time Effect.

	Preexercise EMM (SE)	Postexercise EMM (SE)	M square^a	F	$η_{p}^{2}$
Disgust	0.56 (0.05)	0.34 (0.05)	1.05	25.89**	.38
Moral disgust	0.54 (0.05)	0.30 (0.04)	1.23	37.58**	.47
Anxiety	0.61 (0.04)	0.35 (0.04)	1.58	44.96**	.51
Guilt	0.43 (0.05)	0.27 (0.04)	0.57	12.30*	.22
Shame	0.53 (0.05)	0.25 (0.04)	1.70	41.14**	.49
Anger	0.54 (0.04)	0.25 (0.04)	1.84	31.49**	.42
Sadness	0.64 (0.03)	0.35 (0.04)	1.85	50.46**	.54
Happiness	0.21 (0.03)	0.32 (0.03)	0.28	9.70*	.18

Note. EMM = estimated marginal mean.

For all comparisons, df = 1.

p < .01. **p < .001.

Figure 2.

Emotion ratings pre- and postintervention for CD and CC.

Relations Between Trauma Symptoms and Moral Disgust, Shame, and Guilt

Trait measures

Contrary to predictions, negative zero-order Pearson’s correlations were found between trait moral disgust and PTSS (TDDS_moral and PTCI total score, r(45) = −.35, p < .05; MDS and total PCL-C score at a trend level: r(45) = −.28, p = .06), and trait guilt and PTSS (TOSCA_guilt and PTCI total score, r(45) = −.31, p < .05). Participant scores on a trait measure of shame (TOSCA_shame) were not significantly correlated with any measure of PTSS. However, in support of our hypothesis, zero-order Pearson’s correlations showed that PTSS were significantly positively associated with trauma-related guilt in study participants. Specifically, positive correlations were found between TRGI_distress and PCL-C total score (r(44) = .34, p < .05), and between TRGI_distress and IES-R total score (r(44) = .44, p < .01).

State measures

Correlations between PTSS and state measures of moral disgust, shame, and guilt partially supported our hypothesis. Significant zero-order Pearson’s correlations emerged between PTSS and pre-intervention VAS ratings of guilt (PTCI: r = .39, p = .008) as well as shame (PTCI: r = .46, p = .001; PCL-C: r = .37, p = .01). However, significant relations between PTSS and state disgust and moral disgust were not observed.

Moderator analyses

To ensure that moderator effects did not account for the absence of significant correlations between moral disgust and PTSS observed in this study, linear regression tests examined the significance of disgust propensity (TDDS total score) and moral disgust propensity (MDS) as moderators for the relations between PTSS (as measured by PCL-C) and VAS ratings of state disgust and moral disgust, respectively. The results of these moderator analyses were not found to be significant (disgust: adjusted R² = −.02, p = .59; moral disgust: adjusted R² = .02, p = .30).

Manipulation Check

On Manipulation Check Form B, 11 participants in the CD condition indicated that they “used the technique somewhat” (44%), and 14 indicated that they “definitely used the technique” (56%) during the experimental session. For the CC condition, 7 participants indicated that they “used the technique somewhat” (35%) and 13 indicated that they “definitely used the technique” (65%). Chi-square analyses revealed no significant differences between conditions in participant-reported compliance in the experimental session (p > .05).

Internal Consistency

All of the screening measures used in the present investigation demonstrated good to excellent internal consistency, both in the screening sample (N = 445) and in the group who participated in the study (n = 45), with the exception of the PANAS, which had acceptable internal consistency in the study sample (see Table 2).

Table 2.

Internal Consistency (Cronbach’s α) for Screening Measures as Used in Current Study.

	MDS	TDDS	PANAS	TOSCA-3	TRGI	PCL-C	IES-R	PTCI
Screening sample (N = 445)	.88^a	.91^b	.81^a	.88^a	.95^b	.93^b	.95^b	.96^b
Study participants (n = 45)	.84^a	.91^b	.67^c	.78^a	.94^b	.76^a	.85^a	.94^b

Note. MDS = Moral Disgust Scale; TDDS = Three Domain Disgust Scale; PANAS = Positive and Negative Affect Schedule; TOSCA-3 = Test of Self-Conscious Affect–3; TRGI = Trauma-Related Guilt Inventory; PCL-C = Posttraumatic Checklist, Civilian Version; IES-R = Impact of Events Scale, Revised; PTCI = Posttraumatic Cognitions Inventory.

Good internal consistency.

Excellent internal consistency.

Acceptable internal consistency.

Discussion

This proof of concept project had two hypotheses. First, it was expected that CD would be more effective than a cognitive challenge exercise at reducing moral disgust, shame, and guilt in individuals with elevated PTSS during a single laboratory session. It was also expected that, within this sample of participants, both trait and state disgust, moral disgust, shame, and guilt would be related to PTSS severity assessed via self-report questionnaires and VAS ratings, respectively. Negative emotions (including disgust, moral disgust, shame, and guilt) evidenced large reductions in both CD and CC conditions following ideographic trauma scripts. However, there were no significant differences between the CD and CC exercises, which remained to be the case when grouping participants by trauma type (interpersonal vs. non-interpersonal). Correlational analyses revealed a significant positive association between trait and state trauma-related guilt and PTSS, as well as state shame and PTSS. However, relations were not observed between PTSS and trait or state disgust and moral disgust.

Although a priori hypotheses received mixed support, this work is a novel contribution to the budding literature examining the role of moral disgust, shame, and guilt in posttraumatic reactions. First, the results confirm that state moral disgust, shame, and guilt are relevant to posttraumatic stress responses, as reduced by laboratory-based, ideographic trauma scripts. Although preliminary, the current findings also show that CD was associated with a decrease in negatively valenced, moral, evaluative emotions equally as much as an exercise approximating existing empirically supported treatments for PTSD (e.g., Cahill et al., 2009). In light of these findings, CD and other acceptance-based therapeutic techniques may be viable alternatives for treating moral disgust, shame, and guilt reactivity in PTSS, especially for individuals who are not responsive to more dialectic interventions such as traditional CBT for trauma, or those who find these therapeutic methods off-putting (Olatunji, Deacon, & Abramowitz, 2009). For exposure therapy, an acceptance-based intervention such as CD may serve as a treatment prelude to decrease noxious trauma-related emotions (disgust, moral disgust, shame, guilt) that may be less responsive to exposure before turning attention to remaining fear responses with the exposure interventions. In the context of cognitive processing therapy, CD could be administered adjunctively, as viewing one’s thoughts from an objective perspective is not only commensurate with cognitive reappraisal but also necessary to engage in such techniques. The finding that previous treatment did not have a significant effect on outcome demonstrates that individuals may benefit from acceptance-based interventions for moral, disgust-based PTSS regardless of treatment history or psychoeducation.

The fact that significant correlations were not found between PTSS severity and both state and trait disgust and moral disgust was an unexpected result of the present study. The lack of relations observed between PTSS and moral disgust does not support the relatively novel hypothesis that moral disgust may be a distinct form of emotional reactivity in some presentations of posttraumatic stress. Yet, given previous evidence that disgust (Badour et al., 2012; Badour et al., 2011; Badour, Feldner, Blumenthal, et al., 2013; Engelhard et al., 2011) and moral disgust (Arocho et al., 2013) do play a role in PTSS, the methodological limitations of the current study must be explored in light of these null findings. First, the trait-based measures used in this study—though the “gold standards” of existing self-report questionnaires for disgust, moral disgust, shame, and guilt—did not specifically assess these emotions in the context of PTSS. As suggested by the induction of disgust, moral disgust, shame, and guilt in response to trauma scripts in the present study, this constellation of emotional reactivity in PTSS may arise as state emotions in response to trauma-related thoughts or memories, rather than emotional propensities as were assessed by the trait measures at baseline in this investigation (Cohen, Wolf, Panter, & Insko, 2011; van Overveld et al., 2006). Furthermore, the fact that the TRGI, a measure of guilt specifically related to posttraumatic stress, was the only trait measure of evaluative moral emotions that was significantly correlated with self-reported PTSS in this study suggests that trauma-focused measures of moral disgust, shame, and guilt may be needed to accurately capture the precise role of these constructs in the context of PTSS. The current findings align with a long-standing body of literature highlighting problems in validly defining and assessing trait disgust (Olatunji, Williams, et al., 2007; Rozin, Haidt, & McCauley, 2000; Tybur et al., 2009), guilt, and shame (Cohen et al., 2011; Harder, Cutler, & Rockart, 1992; Tangney, 1996) with self-report measures.

With regard to the lack of significant relations that emerged between PTSS and state moral disgust, other methodological limitations of the present study must be considered. The procedures in this study requested that participants rate disgust and moral disgust without formally defining these terms. Perhaps verbal representations of disgust and moral disgust are not as accessible to participants as are the constructs of shame and guilt, which have been studied in the scientific community for much longer and may be better understood within lay language. Future work should advance the methods used in this study by more precisely describing and assessing disgust and moral disgust. First, clearer definitions for the constructs of disgust and moral disgust should be provided for participants. Multimodal assessments of disgust and moral disgust should also be used, integrating behavioral measures such as behavioral avoidance tasks (e.g., Olatunji, Lohr, Sawchuk, & Tolin, 2007; Rozin, Haidt, McCauley, Dunlop, & Ashmore, 1999), engagement in cleansing behaviors (e.g., Erickson et al., 2011), and implicit associations tests (e.g., Rüsch et al., 2011) along with self-report instruments to comprehensively measure this constellation of emotional reactivity.

There were several additional limitations to this study, many of which are related to the preliminary nature of this investigation. First, the non-clinical sample used in the current study (undergraduate psychology students with elevated PTSS) may limit the generalizability of findings to a larger population of individuals with trauma symptoms, including those diagnosed with PTSD. However, the analog sample used in this study is in line with evidence that individuals do suffer from distress and impairment related to a continuum of PTSS, not only when criteria are met for PTSD diagnosis (Marshall et al., 2001; Ruscio et al., 2002; Zlotnick et al., 2002). Another limitation of the sample was the inclusion of individuals who had experienced a range of traumatic events. This concern is especially pertinent given the interpersonal nature of moral and disgust-related emotions. However, post hoc analyses accounting for trauma type did not reveal significant differences in results for interpersonal versus non-interpersonal traumas. Furthermore, because ACT-informed interventions are intended to be transdiagnostic, using a sample with various types of traumatic experiences may have actually increased the ecological validity of the current study. Because this study was the first to examine CD as an intervention for negatively valenced, moral, evaluative emotions in posttraumatic reactions, we wished to lay a conceptual and methodological foundation for future investigation of CD in reducing moral disgust-, shame-, and guilt-based PTSS on a continuum of severity and diversity (Badour et al., 2012; Rounsaville, Carroll, & Onken, 2001).

Next, the investigators’ ability to infer causality of the interventions in reducing negative emotions was limited by the absence of a true control condition in this study. Although CC was modeled after a well-established technique for treating PTSD (e.g., Resick et al., 2008), the exercise functioned as a conservative comparison condition rather than an inactive control. However, the large effect sizes displayed by both CD and CC ( $η_{p}^{2}$ ranging from .18 to .54) compare favorably with the small-to-medium effect sizes shown in tests of other laboratory-based strategies for reducing negative emotions (average d₊ ranging from 0.00 to 0.36; Webb, Miles, & Sheeran, 2012). Viewed within the broader context of laboratory-based emotion-reduction techniques, the notably larger effect sizes of the CD and CC interventions support the interpretation that these strategies drove the emotional changes observed in the current study rather than statistical artifacts such as the reactive effects of repeated assessment. Furthermore, as it has been shown that script-driven imagery (SDI) procedures typically increase negative emotions among trauma-exposed individuals (e.g., Badour et al., 2011; Pitman et al., 1987), the evidence that negative emotional reactivity decreased following the interventions in this study further supports the attribution of these results to the CD and CC techniques.

Relatedly, this study did not employ the standardized SDI protocol as has been used in many studies inducing PTSS in the laboratory (e.g., Pitman et al., 1987). Due to the methodological alterations to these procedures in this experiment (i.e., trauma script written and re-read rather than audio-recorded; absence of a neutral autobiographical script), the reliability and validity of the ability of SDI procedures to evoke trauma thoughts, emotions, and memories can only be generalized to the procedures of the present study in a limited way. However, the fact that self-reported negatively valenced, evaluative, moral emotions decreased with large effect sizes during the experiment suggests that the modified trauma script procedures used in the present study were successful in alleviating trauma-related internal experiences. Nevertheless, future extensions of this work should adhere to standardized SDI procedures more strictly to promote greater comparability and generalizability to the existing literature on laboratory-based emotional reactivity in individuals with PTSS.

Other methodological limitations of this study include the fact that the interventions were brief (1 hr), and thus cannot be equated with lasting therapeutic efficacy. In addition, only the immediate effects of the interventions were measured. This time frame is of note because existing literature suggests that acceptance-based interventions for moral evaluative emotions may be most effective in the long term (e.g., 4 months posttreatment; Luoma et al., 2012). However, the time-limited interventions and assessments used in this investigation are consistent with Stage I research on behavioral therapy development (Rounsaville et al., 2001), which best describes the preliminary nature of this pilot study.

There are also drawbacks to utilizing an acceptance-based intervention for PTSS, especially the CD exercise, which asks participants to visualize themselves as a neutral observer to their private mental events. CD may be problematic for use with some trauma-exposed individuals with severe PTSD symptoms (Wolf et al., 2012), who may have difficulty maintaining a consistent sense of self in the face of shifting internal experiences (Batten & Hayes, 2005; Orsillo & Batten, 2005), or who may experience the related phenomenon of dissociation (Nijenhuis & van der Hart, 2011) that has phenotypic overlap with the “neutral observer” component of CD. In addition, the visuomotor behavior of closing one’s eyes (as instructed during CD) has been associated with dissociative re-experiencing events or “flashbacks” (Hellawell & Brewin, 2002; Rauch & Foa, 2006). Moderate discomfort with participating in the CD exercise with eyes closed was anecdotally observed in approximately 7% of participants in this study. However, after opening their eyes, these participants completed the study procedures and tolerated them well. In spite of the potential limitations of using the CD strategy in some members of a trauma-exposed population, the striking reduction in symptoms associated with the use of CD in this study suggests that the benefits to this novel approach may outweigh its potential disadvantages.

Another limitation of this study is that the first author (R.O.) served as the experimenter for one third of participants and also trained the other experimenters in study procedures. However, the fact that the findings of this study did not fully support the major hypothesis is evidence that the first author’s involvement in execution of procedures likely did not bias study outcomes. Furthermore, the absence of significant differences in outcome between the four experimenters as well as across sites suggests that all experimenters delivered study procedures in a standardized way. Other studies of acceptance-based interventions for difficult-to-treat populations have also successfully included the principal investigator in study procedures during the initial phases of investigation (e.g., Gratz & Gunderson, 2006).

Finally, the fact that independent raters were not used for the experimental manipulation check of participant comprehension of assigned thought exercises is a limitation of this pilot study. In future extensions of this investigation, the use of independent raters would strengthen the reliability and validity of manipulation check procedures. However, the additional Manipulation Check B in which all participants reported that they were either “definitely” or “somewhat” able to utilize their assigned techniques supports the conclusion that participants successfully engaged in the interventions in this study.

Despite these potential limitations, a notable strength of the current study is the diversity of the sample. First, sampling individuals from both Fordham University and the University of Arkansas means that the study included participants from northeastern and southern geographic locations, more and less dense urban areas, and both public and private educational institutions. While this is a considerably heterogeneous sample, between-site comparability was demonstrated for all demographic items besides age, as well as the distribution of trauma types. These data lend notable external validity to the findings of this investigation. In addition, the experimental design of this study suggests high internal validity and enables an interpretation of results that infers potential causality of the CD intervention in reducing negatively valenced, moral, evaluative emotions related to trauma.

Due to the preliminary nature of this work, the findings prompt many questions for further research. First, it will be critical to extend the results of this pilot study to clinical samples to determine if acceptance-based strategies are efficacious for reducing negatively valenced, moral, evaluative emotions in individuals with full PTSD in addition to the partial or subclinical symptoms displayed by most individuals in this sample. Future work should also identify specific treatment-seeking populations for whom acceptance-based approaches may be most suitable, the investigation of which may include differences in treatment adherence, retention, and therapeutic alliance in CD versus traditional CBT approaches. In addition, future studies should examine the efficacy of acceptance-based interventions such as CD in augmenting existing PTSD treatment protocols, including evaluation of specific configurations of ACT-informed interventions with various cognitive-behavioral approaches for trauma (i.e., as prelude, adjunct, etc.). Future research should also examine disgust-specific mechanisms of action in CD, especially for particular trauma types, to guide further specialization of treatment. To this end, other advances of this research should draw upon OCD treatments that target mental contamination, as such symptoms often overlap with PTSS following traumatic moral transgressions such as sexual assault (e.g., Badour et al., 2012).

Finally, it will be important to expand the findings of this study to a longer and more intensive acceptance-based intervention that incorporates a greater number of sessions, a more comprehensive explanation of ACT principles, and between-session “homework” assignments. In such research, outcome measures should be expanded to include assessment of not only state emotions but also the internalization of central ACT principles such as psychological flexibility and engagement in valued living. Implementing a longer term intervention would also allow future investigators to conduct follow-up assessments to compare the effects of acceptance-based treatment and other CBT interventions over time. Such work could potentially extend the findings of the current study to more formalized treatment applications and help determine whether acceptance-based interventions confer long-term advantages over traditional CBT for treating moral disgust, shame, and guilt reactivity in posttraumatic stress reactions.

Footnotes

Acknowledgements

We thank Erin Brannan, Michael Drosos, and Alex Mager for their contributions to the work reported in this manuscript.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dean McKay receives royalties from SAGE Publications, Elsevier, Johns Hopkins Press, Springer Science + Business, American Psychological Association, and Springer Publications (for book royalties and as Editor of Journal of Cognitive Psychotherapy).

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported in part by an unrestricted research grant to Dean McKay from Fordham University. Dr. McKay is also supported in part by a Faculty Research Grant from the Graduate School of Arts & Sciences at Fordham University.

Author Biographies

Rachel Ojserkis, MA, is a doctoral student in clinical psychology at Fordham University. Her research examines the role of disgust in the development, maintenance, and treatment of psychological disorders, including posttraumatic stress and obsessive-compulsive disorders.

Dean McKay, PhD, is a professor of psychology at Fordham University and President (2013-2014) of the Association for Behavioral and Cognitive Therapies. His primary areas of interest are anxiety and obsessive-compulsive disorders and their treatment across the age span.

Christal L. Badour, MA, completed her graduate training in clinical psychology at the University of Arkansas in Fayetteville. She is currently a predoctoral intern at the Medical University of South Carolina/Ralph H. Johnson VAMC in Charleston. Her research focuses on the role of affective expression/regulation in posttraumatic stress.

Matthew T. Feldner, PhD, is an associate professor in the Department of Psychological Science at the University of Arkansas and adjunct associate professor at the Laureate Institute for Brain Research. His research focuses on panic disorder, posttraumatic stress disorder (PTSD), and the common overlap between drug use behavior and these conditions.

Justin Arocho, MA, is a doctoral candidate in clinical psychology at Fordham University. His research focuses on the role of moral disgust in obsessive-compulsive disorder (OCD), PTSD, and other psychological conditions.

Courtney Dutton, MA, is currently enrolled in the doctoral program in clinical psychology at the University of Arkansas. Her research interests focus on the role of social functioning in the maintenance and treatment of comorbid PTSD and substance use.

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