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. Author manuscript; available in PMC: 2022 Apr 6.
Published in final edited form as: Violence Against Women. 2021 Feb 18;28(1):107–125. doi: 10.1177/1077801220988350

Avoidance Coping Partially Accounts for the Relationship between Trauma-Related Shame and PTSD Symptoms following Interpersonal Trauma

Jordyn M Tipsword 1, Jazmin L Brown-Iannuzzi 2, Alyssa C Jones 1, Jessica Flores 1, Christal L Badour 1
PMCID: PMC8985344  NIHMSID: NIHMS1792081  PMID: 33602037

Abstract

Research has demonstrated that individuals experiencing trauma-related shame exhibit greater PTSD symptoms (e.g., La Bash & Papa, 2013). However, little research has investigated additional factors relevant to the shame-PTSD relationship. The current study examined the role of avoidance and approach coping in accounting for the trauma-related shame-PTSD association among 60 women who had experienced interpersonal trauma. Indirect effects tests revealed that avoidance coping partially accounted for the association between shame and interviewer-assessed PTSD symptoms, β = 0.21, SE = 0.08, 95% CI [0.03, 0.36]. These findings offer a novel contribution to the growing literature examining negative outcomes following interpersonal trauma.

Posttraumatic Stress Disorder (PTSD) is an impairing psychological condition in which individuals who have experienced trauma display several hallmark symptoms, including re-experiencing the traumatic event, avoidance of stimuli that elicit reminders of the traumatic experience, negative changes in cognition or affect, and alterations in arousal and reactivity (American Psychiatric Association [APA], 2013). Although PTSD can result from exposure to a variety of traumatic events, individuals with a history of interpersonal trauma have been identified as being particularly at-risk for developing PTSD (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993). Interpersonal trauma broadly refers to acts that involve personal violation, assault, and/or physical or sexual violence (Badour, Resnick, & Kilpatrick, 2017; Lilly & Valdez, 2012), including sexual assault, intimate partner violence, and physical assault, as well as childhood sexual or physical abuse (Lilly & Valdez, 2012). Given that those with a history of interpersonal trauma are particularly likely to develop PTSD as a result of that traumatic experience, research has increasingly begun to investigate the nature and development of PTSD among that population (e.g., Lilly & Valdez, 2012).

In particular, an expanding body of research has begun to investigate the interrelationships between PTSD symptoms and specific negative emotions, such as anger, fear, guilt, shame, disgust, and sadness (e.g., Hathaway, Boals, & Banks, 2010); however, our current understanding of the mechanisms linking negative emotions to PTSD outcomes is limited (La Bash & Papa, 2013). Whereas previous research often focused on the relationship between fear and PTSD, recent research has been trending toward examining the relationship between other negative emotions and PTSD symptoms (e.g., Hathaway et al., 2010) in an attempt to more fully understand the negative emotional consequences of trauma.

Shame in particular tends to be prevalent among those who have experienced interpersonal trauma (Badour et al., 2017) and may contribute a great deal to our understanding of PTSD (Saraiya & Lopez-Castro, 2016). Shame has been conceptualized as a “negative evaluation of the self in the context of trauma with a painful affective experience, and a behavioral tendency to hide and withdraw from others to conceal one’s own perceived deficiencies” (Øktedalen, Hagtvet, Hoffart, Langkaas, & Smucker, 2014, p. 604). Previous research has linked shame to a variety of negative outcomes, including aggression (Velotti, Elison, & Garofalo, 2014), suicidal ideation (Bryan, Morrow, Etienne, & Ray-Sannerud, 2013), and PTSD (La Bash & Papa, 2013; Saraiya & Lopez-Castro, 2016). Although existing studies have investigated the factors linking other negative emotions – such as guilt (e.g., Held, Owens, & Anderson, 2015) and anger (e.g., Olatunji, Ciesielski, & Tolin, 2010) – to PTSD symptoms, the literature on trauma-related shame is less extensive in comparison. This is especially noteworthy given that the experience of shame is relatively common following exposure to interpersonal trauma (e.g., Badour et al., 2017; La Bash & Papa, 2013).

Given the aforementioned implications of shame for interpersonal trauma-related PTSD, efforts to investigate it have increased in recent years (Saraiya & Lopez-Castro, 2016). These recent investigations may have been motivated, in part, by changes in the conceptualization of PTSD that emerged in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013; Badour et al., 2017). The DSM-5 recognized a broader range of emotional reactions to trauma than previous editions via the inclusion of PTSD criterion D4, which involves persistent experiences of negative affect that arise or worsen following traumatic events (e.g., fear, horror, anger, guilt, or shame; APA, 2013, p. 271). With shame now appearing directly in the DSM-5 criteria for PTSD, increased interest in the link between trauma-related shame and PTSD has ensued.

Though shame has been linked to the emotional experience of guilt, research has sought to disentangle the unique impact of trauma-related shame from that of trauma-related guilt (e.g., Gilbert, 2003; Held et al., 2015; Leskela et al., 2002; Taylor, 2015), which refers to a “self-conscious affect that relates to a sense of responsibility and the cause of harm to others” (Lee, Scragg, & Turner, 2001, p. 456). Such studies have found that while trauma-related guilt occurs as a result of feeling bad about particular actions or behaviors, trauma-related shame involves more global negative attributions about the self (e.g., Lee et al., 2001; Leskela et al., 2002). Furthermore, previous work has found that shame is a better predictor of PTSD symptoms than is guilt (Bannister, Colvonen, Angkaw, & Norman, 2019). Thus, shame can be characterized as a unique emotional response to trauma that, accordingly, may contribute to negative trauma-related outcomes in unique ways. For example, some have proposed that the experience of shame may lead to negative trauma-related outcomes by encouraging individuals to either avoid stimuli that might trigger reminders of the trauma or withdraw from previous responsibilities and relationships (Øktedalen et al., 2014; Saraiya & Lopez-Castro, 2016). Others have emphasized that trauma-related shame may manifest in the form of harsh self-judgment, including self-condemnation and self-scrutiny (e.g., Lee et al., 2001). As such, additional research is needed to further clarify the nature of trauma-related shame, including the thoughts and behaviors associated with it.

In addition, previous research has established that trauma-related shame, like other trauma-related emotions, can either lessen in intensity or persist over time due to a variety of factors, including deficits in emotion regulation (e.g., Villalta, Smith, Hickin, & Stringaris, 2018) and substance use (e.g., Holl et al., 2017; Ullman, Relyea, Peter-Hagene, & Vasquez, 2013). However, less research has empirically tested the factors that might influence the relationship specifically between trauma-related shame and PTSD symptoms. Thus, the present study aimed to evaluate whether specific coping strategies might account for the link between trauma-related shame and PTSD symptom severity following interpersonal trauma.

One manner in which individuals who have experienced interpersonal trauma may attempt to process that event and the negative emotional consequences of it is through the use of coping strategies. Coping strategies refer to behavioral and cognitive techniques employed to help an individual respond to stressors that are viewed as being overwhelming (Folkman & Lazarus, 1988; Roth & Cohen, 1986). One common method of examining coping behavior involves dividing potential strategies into two categories: approach coping and avoidance coping (e.g., Tiet et al., 2006). Whereas approach coping involves focusing on addressing the root causes of feelings of distress (e.g., seeking support from others, planning; Roth & Cohen, 1986), avoidance coping involves diverting attention away from the problem or event causing distress (Folkman & Lazarus, 1988; Tiet et al., 2006) through behaviors like substance use or avoidance (Roth & Cohen, 1986). As such, persistent use of avoidance coping has been associated with maladaptive outcomes.

Relatedly, research has consistently linked utilization of avoidance coping strategies with more severe PTSD symptoms among those who have experienced interpersonal trauma (e.g., Krause, Kaltman, Goodman, & Dutton, 2008; Ullman et al., 2013). In contrast, use of approach coping strategies has been linked to more effective social functioning and better family relationships among individuals who have experienced trauma (Tiet et al., 2006), as well as reduced PTSD symptoms (e.g., Hassija, Luterek, Naragon-Gainey, Moore, & Simpson, 2012). In addition, preliminary research suggests that the use of avoidance coping strategies may account, in part, for the relationship between specific negative emotions and PTSD symptoms (e.g., Held et al., 2015; Street, Gibson, & Holohan, 2005). As Street and colleagues (2005) affirm, such a finding suggests that the use of avoidance coping may be a common method of responding to trauma because it helps individuals prevent or delay negative emotional reactions that result from traumatic event exposure.

Though a great deal of existing research has highlighted the role of approach and avoidance coping strategies in managing fear- or anxiety-related distress following stressful events (e.g., Roth & Cohen, 1986; Walsh, Fortier, & DiLillo, 2010), it stands to reason that coping may similarly serve as a means of managing other trauma-related negative emotions, including trauma-related shame. Existing work has documented positive associations between shame and avoidance coping both in trauma-exposed samples and non-trauma-exposed samples and has posited that the intense distress associated with shame may elicit avoidance behaviors that serve as a means of reducing short-term distress linked to shame (e.g., Harper, 2011; Van Vliet, 2010; Yi & Kanetkar, 2010). However, research has yet to investigate the potential role of coping strategies in the relationship between trauma-related shame and PTSD symptom severity in particular.

In the current study, it was hypothesized that trauma-related shame would be indirectly linked to PTSD symptom severity via coping strategy utilization (approach vs. avoidance). Specifically, it was expected that trauma-related shame would be associated with lower use of approach coping strategies and higher use of avoidance coping strategies, and that use of approach coping strategies would, in turn, be associated with less severe PTSD symptoms whereas use of avoidance coping strategies would be associated with more severe PTSD symptoms.

Method

Participants

Sixty women aged 18 to 66 (Mage = 35.25 years, SD = 13.33) were recruited from the community using paper and electronic flyers. All participants had experienced at least one form of interpersonal trauma, defined here as an experience that occurred at any point during the individual’s lifetime involving physical or sexual assault or abuse. An all-female sample was recruited as women are more likely than men to experience certain forms of interpersonal trauma (e.g., sexual trauma; Kessler et al., 1995; Kilpatrick et al., 2013) and existing research has documented that women experience shame more frequently and/or readily than men (Else-Quest, Higgins, Allison, & Morton, 2012; Lutwak & Ferrari, 1996). Those who responded to advertisements but did not report a form of interpersonal trauma as their primary traumatic experience were excluded from the study. In addition, individuals who indicated they had experienced interpersonal violence within the previous 30 days were required to delay participation until at least one month had elapsed following that experience to ensure that we were evaluating posttraumatic experiences rather than acute trauma-related distress.

Participants identified as 66.7% White, 23.3% African American, 3.3% Multiracial, 1.7% Native Hawaiian/Pacific Islander, 1.7% Asian, 1.7% American Indian/Alaska Native, and 1.7% of participants reported belonging to another racial group. Four participants (6.7%) identified as Hispanic. Participants’ incomes ranged from <$20,000 to >$100,000 and the most frequently reported household income was < $20,000 (36.7%). In addition, all participants reported having completed at least some education beyond high school. Within our sample, 16.7% of participants were college graduates and 18.3% had completed either graduate or professional school.

Approximately 16.7% of our sample reported having experienced a single form of physical or sexual trauma, while the remaining 83.3% reported having experienced multiple forms. The mean age at which participants experienced the index – or most distressing – interpersonal trauma event was 17.98 years (SD = 7.93). Participants endorsed having experienced the following forms of physical and sexual trauma: having intercourse or engaging in oral or anal sex against their will (73.3%); being forced to touch the private parts of another individual or being forcibly touched by another individual (73.3%); being in a situation involving attempted forcible and unwanted sexual contact (53.3%); being attacked with a weapon (40.0%); being injured by an attack without a weapon (35.0%); and being beaten, spanked, or pushed to the point of injury (45.0%). Additionally, 50.0% (n = 30) of participants met criteria for a current diagnosis of PTSD based on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; Weathers et al., 2013a).

Measures

Trauma history.

History of interpersonal trauma was assessed via the Physical and Sexual Experiences subscale of the Trauma History Questionnaire (THQ; Green, 1996). Sample items on this six-item subscale include “Has anyone ever made you have intercourse or oral or anal sex against your will?” and “Has anyone in your family ever beaten, spanked, or pushed you hard enough to cause injury?” For each event, participants indicated whether they had ever experienced it (yes or no). For each item to which they responded affirmatively, participants were asked how many times and at approximately what age(s) they had experienced that event. The THQ has demonstrated satisfactory interrater reliability (kappas .57 – .76) and test-retest reliability (stability coefficients over 2–3 months ranging from .51 to .91; Hooper, Stockton, Krupnick, & Green, 2011).

PTSD symptoms.

Symptoms of PTSD were assessed via the PTSD Checklist for DSM-5 (PCL-5; Weathers et al., 2013b) and the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; Weathers et al., 2013a) to provide for both self-report and interviewer-evaluated past-month PTSD symptoms, respectively. The PCL-5 is a 20-item self-report measure of PTSD that provides information concerning both the frequency and overall severity of PTSD symptoms. For each item, participants indicated the extent to which the described behavior or experience bothered them during the past month using a Likert-type scale (0 = Not at all to 4 = Extremely). A total score for the PCL-5 was calculated for each participant by summing scores for all scale items. Missing data for one PCL-5 item for one participant was determined to be missing at random and was therefore imputed using expectation-maximization procedures. The PCL-5 has exhibited strong reliability in both initial tests of its psychometric properties (α = .94; Blevins, Weathers, Davis, Witte, & Domino, 2015) and in the present sample (α = .96).

The CAPS-5 is a semi-structured clinical interview designed to evaluate frequency and intensity of 20 DSM-5 PTSD symptoms over the past month. Each item is rated on a five-point scale (0 = Absent to 4 = Extreme / incapacitating). The CAPS-5 exhibits strong reliability and validity (e.g., Weathers et al., 2018) and is a well-established measure of PTSD symptoms. Internal consistency in the present study was excellent (α = .90). A graduate researcher trained in the CAPS-5 conducted all participant interviews, and 20% of interviews were randomly selected and coded for interrater reliability using Cohen’s Kappa for diagnostic reliability (κ = 1.0) and two-way mixed, absolute, single-measures ICCs for reliability in individual symptom severity ratings (ICCs: .92 – 1.0; Hallgren, 2012). A total symptom severity score for the CAPS-5 was calculated using the same procedures utilized for the PCL-5. PTSD diagnostic status was also computed based on the SEV2 scoring rule for determining symptom counts within each criterion (Weathers et al., 2018).

Trauma-related shame.

Trauma-related shame was assessed via responses to the Trauma-Related Shame Inventory (TRSI; Øktedalen et al., 2014), which is a 24-item self-report measure designed to evaluate the presence and severity of shame linked to traumatic experiences. Participants identified the extent to which each statement applied to them using a Likert-type scale (0 = Not true of me to 3 = Completely true of me). Scores for all items were then summed to create a total index of trauma-related shame for each participant, wherein higher total scores indicated greater levels of shame. The TRSI has demonstrated satisfactory reliability and validity in previous research (e.g., Øktedalen et al., 2014) and exhibited strong reliability within our sample (α = .97).

Approach and avoidance coping.

A modified version of the Brief COPE (Carver, 1997) was used to assess approach and avoidance coping in response to the index trauma. Items on the Brief COPE are designed to correspond to one of fourteen coping subscales. In line with previous research using the Brief COPE to investigate approach and avoidance coping (e.g., MacAulay & Cohen, 2013), we defined approach strategies as those that comprised the planning and active coping subscales (four items total), and avoidance strategies as those that comprised the denial and behavioral disengagement subscales (four items total). Additional research has also utilized the eight selected items within broader scales measuring approach and/or avoidance coping behavior, lending support to their use for this purpose (e.g., Schnider, Elhai, & Gray, 2007; Snell, Siegert, Hay-Smith, & Surgenor, 2011). Together, the four subscales corresponded to eight total coping-related items – four assessing approach coping strategy use and four assessing avoidance coping strategy use. For each item, participants indicated how often they had engaged in the described behavior using a Likert-type scale (1 = I haven’t been doing this at all to 4 = I’ve been doing this a lot). Overall scores for approach and avoidance coping were calculated for each participant by summing responses to selected items, with lower scores indicating less frequent use of each type of coping. Cronbach’s alpha values for the approach (α = .80) and avoidance coping subscales (α = .70) in our study suggested moderate and satisfactory reliability, respectively.

Procedure

Women with a history of interpersonal trauma were recruited as part of a larger study focused on understanding emotional experiences and emotion regulation in the context of interpersonal trauma. Women who contacted the lead researcher were then screened over the phone to assess whether they met the study eligibility criteria. Those who met criteria completed an online questionnaire battery and were then asked to attend two laboratory visits to complete interviews, self-report measures, and a laboratory task not relevant to the current investigation. Participants also completed two weeks of daily diary assessments. Data for the current investigation were all collected from baseline measures completed online through the survey platform Qualtrics prior to (PCL-5) or during (CAPS-5, TRSI, and Brief COPE) the laboratory visits; the present study did not utilize any data from daily diary assessments. Participants provided online consent prior to completing the baseline measures and written informed consent at the first laboratory session. All participants were debriefed after completing the study. Participants received $30 for each laboratory visit and could earn a maximum total of $160 if they chose to participate in all parts of the study. Data collection was approved by the university’s Institutional Review Board (IRB).

Data Analytic Plan

First, descriptive statistics and zero-order correlations were examined. Separate indirect effects models were then conducted in SPSS 26 using the PROCESS custom dialog (Hayes, 2013) to test the hypotheses that trauma-related shame would positively relate to: a) self-reported and b) interviewer-assessed PTSD symptom severity via avoidance coping and negatively relate via approach coping. As assessments of trauma-related shame (TRSI) and coping (Brief COPE) were administered during the same in-lab visit, temporal precedence was unable to be established for those variables; thus, both indirect effects models were cross-sectional. Both unstandardized and standardized (M = 0; SD = 1) path coefficients were examined to aid in interpretation. A bias-corrected (BC) 95% confidence interval (CI) was used as the criterion for evaluating significance of the indirect effects. Indirect effects were considered statistically significant if zero was not included in the 95% CI generated based on the established sampling distribution. Bootstrapping with 5000 resamples was employed to assess for the presence of indirect effects, as well as to contrast the size of individual indirect effects (Hayes, 2009; Williams & MacKinnon, 2008). Additional models were evaluated using age at index trauma and whether participants experienced single vs. multiple experiences of interpersonal trauma as covariates. Inclusion of these covariates did not change the primary results of the process models described below.

Results

Descriptive Statistics and Zero-Order Correlations

Descriptive statistics and zero-order correlations are presented in Table 1. Overall, participants reported using approach coping strategies more often than avoidance coping strategies. Furthermore, the mean PCL-5 PTSD symptom severity score among our sample was 32.57 (SD = 20.20), which corresponds to borderline clinically significant symptoms based on recommended clinical cut-point scores ranging from 31 to 38 in recent research (e.g., Bovin et al., 2016; Hoge et al., 2014; Wortmann et al., 2016).The mean CAPS-5 PTSD symptom severity score was 21.77 (SD = 12.93), which corresponds to mild to moderate PTSD symptom severities based on recommended score ranges for the CAPS-5 (Weathers et al., 2018).

Table 1.

Descriptive Data and Zero-Order Correlations for All Model Variables

Variable 1 2 3 4 5 M (SD) Range
1. Trauma-related shame (TRSI) - .32* .59** .68** .60** 22.22 (18.04) 0–84
2. Approach coping (Brief COPE) - - .22 .36** .08 8.83 (3.33) 4–16
3. Avoidance coping (Brief COPE) - - - .53** .58** 6.05 (2.38) 4–16
4. PTSD Symptom Severity (PCL-5) - - - - .67** 32.57 (20.20) 0–80
5. PTSD Symptom Severity (CAPS-5) - - - - - 21.77 (12.93) 0–80
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CAPS-5 Clinician-Administered PTSD Scale for DSM-5, PCL-5 PTSD Checklist for DSM-5, TRSI Trauma-Related Shame Inventory

Note.

*

p < .05

**

p < .01

At the zero-order level, avoidance coping was positively correlated with trauma-related shame and both self-reported and interviewer-assessed PTSD symptoms. Contrary to hypotheses, approach coping was also positively correlated with trauma-related shame and self-reported (but not interviewer-assessed) PTSD symptom severity. As expected, trauma-related shame was also positively correlated with both self-reported and interviewer-assessed PTSD symptoms.

Primary Analyses

Results from the first model predicting interviewer-assessed PTSD symptoms via the CAPS-5 (Weathers et al., 2013a) are displayed in Figure 1. As expected, trauma-related shame was positively related to avoidance coping (Path A1). Contrary to hypotheses, trauma-related shame was also positively related to approach coping (Path A2). After accounting for trauma-related shame, avoidance coping was also positively related to interviewer-assessed PTSD symptoms (Path B1), but the association with approach coping was not significant (Path B2). As expected, indirect effects tests revealed that the pathway from trauma-related shame to interviewer-assessed PTSD symptoms was significant via avoidance coping, Path AB1: B = 0.15, SE = 0.07, 95% CI [0.02, 0.29]; β = 0.21. The non-significant B2 path precluded a test of the AB2 indirect effect.

Figure 1.

Figure 1.

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Results of the indirect effects model predicting clinician-evaluated PTSD symptoms from trauma-related shame via avoidance and approach coping. Unstandardized coefficients and corresponding standard errors are presented with standardized coefficients included in parentheses to aid in interpretation.

*p < .05. **p < .01.

Results from the second model predicting self-reported PTSD symptoms via the PCL-5 (Weathers et al., 2013b) are displayed in Figure 2. Similar to the first model, trauma-related shame was positively related to both avoidance coping (Path A1) and approach coping (Path A2). However, after accounting for trauma-related shame we failed to detect significant associations between avoidance coping (Path B1) or approach coping (Path B2) and self-reported PTSD symptom severity. As such, indirect effects tests were not conducted for this model.

Figure 2.

Figure 2.

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Results of the indirect effects model predicting self-reported PTSD symptoms from trauma-related shame via avoidance and approach coping. Unstandardized coefficients and corresponding standard errors are presented with standardized coefficients included in parentheses to aid in interpretation.

*p < .05. **p < .01.

Discussion

The present study investigated whether coping strategy utilization accounted for the relationship between trauma-related shame and PTSD symptoms among a sample of women with a history of interpersonal trauma. In line with previous research (e.g., Leskela et al., 2002; Stone, 1992), we hypothesized that trauma-related shame would be associated with greater PTSD symptom severity, more frequent use of avoidance coping strategies, and less frequent use of approach strategies. It was further hypothesized that elevated use of approach coping strategies would, in turn, be associated with less severe PTSD symptoms, whereas elevated use of avoidance coping strategies would be associated with more severe PTSD symptoms. Our proposed model was partially supported, with elevated use of avoidance coping strategies partially explaining the relationship between trauma-related shame and severity of interviewer-assessed (but not self-reported) symptoms of PTSD.

Consistent with both our hypotheses and previous research (e.g., Leskela et al., 2002; Stone, 1992; Wilson, Droždek, & Turkovic, 2006), we found a strong positive association between trauma-related shame and PTSD symptom severity, wherein those who experienced greater levels of shame also tended to experience more severe PTSD symptoms. This relationship remained significant even when controlling for age at which the index traumatic event occurred and whether participants had experienced a single incident or multiple incidents involving interpersonal trauma. These results converge with the growing body of work documenting a consistent link between trauma-related shame and elevated PTSD symptoms.

Additionally, we found that trauma-related shame was linked to greater coping efforts involving both avoidance and approach strategies. Although this finding was anticipated for avoidance coping, results revealing a positive association between trauma-related shame and approach coping were contrary to our hypotheses. This is surprising given the substantial literature linking trauma-related shame to a tendency to engage in avoidance coping behaviors over approach coping behaviors (e.g., Held et al., 2015). However, there are several potential explanations for such a finding. First, it cannot be said that individuals in our sample were engaging in approach coping in instances in which they were actively experiencing trauma-related shame. Thus, it is possible that although shame and approach coping were positively associated with one another, participants may have been utilizing those approach strategies to manage other negative trauma-related experiences (e.g., PTSD symptoms) instead of employing them to manage trauma-related shame in particular. In addition, the finding that use of approach coping was not significantly associated with fewer PTSD symptoms also suggests that although individuals in our sample were engaging in approach coping behaviors, those behaviors may not have been effective in reducing PTSD symptoms. Such a conclusion is supported by recent work demonstrating that the processes by which individuals a) select strategies to employ in the management of negative emotion and b) effectively implement those strategies are separate from one another (Kalokerinos, Erbas, Ceulemans, & Kuppens, 2019). As such, it is possible that individuals experiencing high levels of trauma-related shame may utilize approach coping strategies, but may do so in ineffective ways. In such cases, we might fail to see reductions in PTSD symptoms following approach coping behaviors, as occurred in our findings.

Our findings concerning the relationship between trauma-related shame and coping behaviors are also noteworthy given that much work in the coping literature has focused on avoidance coping, considering this to be an index of unhelpful or maladaptive coping strategies (e.g., Krause et al., 2008). However, as our findings highlight, individuals may engage in a variety of coping strategies in response to trauma-related distress. Thus, it is important to consider both avoidance strategies and approach strategies when aiming to evaluate the range of coping behaviors an individual may employ. Furthermore, it is also worth noting that the context surrounding coping behavior may also influence the adaptiveness of a given coping strategy (e.g., Aldao, 2013). For example, coping behaviors that are often deemed maladaptive (e.g., distraction) might prove useful and, in fact, improve an individual’s ability to function in certain situations (e.g., when fulfilling employment responsibilities). As such, it is important to consider the full context within which an individual is functioning when assessing and evaluating the coping behaviors that individual is employing.

In addition, our hypothesis that avoidance coping would partially account for the association between trauma-related shame and PTSD symptoms was supported for interviewer-assessed (but not self-reported) PTSD symptoms. This finding for interviewer-assessed PTSD symptoms aligns well with previous research linking maladaptive coping to adverse outcomes among those experiencing negative trauma-related emotions (e.g., Held et al., 2015). It is worth noting, however, that findings were not consistent with hypotheses when examining self-reported PTSD symptoms. Although use of avoidance coping strategies was positively associated with both interviewer-assessed and self-reported PTSD symptoms at the zero-order level, the association between avoidance coping and self-reported PTSD symptoms failed to reach significance when accounting for trauma-related shame. Further discussion of this discrepancy is warranted. First, it may be the case that the association failed to reach significance after controlling for trauma-related shame due to the relative strength of the correlation between trauma-related shame and self-reported PTSD symptom severity (r = .68). In addition, it could be the case that individuals experiencing trauma-related shame may have difficulty distinguishing between distress associated with trauma-related shame and more general distress associated with PTSD symptoms. Indeed, it has been established that both the experience of PTSD and the experience of trauma-related shame involve a great deal of general distress (e.g., La Bash & Papa, 2013; Resnick et al., 1993), which may further complicate the process of parsing apart distress associated with each individual experience.

Finally, it should be noted that the CAPS-5 is widely considered to be the most valid and reliable measure of PTSD symptoms due to its strong psychometric properties and direct correspondence to all 20 DSM-5 PTSD symptoms (e.g., Geier, Hunt, Nelson, Brasel, & deRoon-Cassini, 2019; Weathers et al., 2018). Although the PCL-5 has been established as a useful measure to utilize when administering the CAPS-5 is unfeasible or inappropriate (e.g., Geier et al., 2019), the CAPS-5 remains the most optimal measure of PTSD symptoms. As a result, findings based on CAPS-5 scores should be weighed more heavily than those based on self-reported PTSD symptom scores, including PCL-5 scores.

In contrast with avoidance coping, we failed to find any support for the hypothesis that approach coping would partially account for the trauma-related shame-PTSD relationship. Although approach coping was positively correlated with trauma-related shame and self-reported PTSD symptoms at the zero-order level, approach coping was not significantly related to either interviewer-assessed or self-reported PTSD symptoms after accounting for the effects of trauma-related shame. This finding was surprising given that previous research has documented a significant negative correlation between use of approach coping strategies and PTSD symptom severity (e.g., Hassija et al., 2012). However, as previously outlined, this discrepancy in findings could be explained by the strong correlation between shame and PTSD symptom severity in our sample, as well as the overlap between distress associated with trauma-related shame and distress associated with PTSD symptoms more broadly.

An additional explanation for these findings diverging from previous research could be that our study focused exclusively on problem-focused methods of approach coping, which involve behavioral approaches to addressing a particular traumatic event (e.g., “I’ve been taking action to try to make the situation better”; Carver, 1997). Although this approach was chosen in alignment with previous research on approach coping, the scope of the methods examined may have been too narrow. In contrast with our approach, existing work on emotional responses to trauma has either focused on emotion-focused methods of approach coping, such as open emotional expression (e.g., Hassija et al., 2012), or a combination of problem-focused and emotion-focused coping methods (e.g., Held et al., 2015). This divergence is potentially significant given that approach coping is generally thought to encompass both problem-focused and emotion-focused coping strategies (Folkman & Lazarus, 1988). Based on that framework, our definition of approach coping was limited in that it only included a portion of all the possible means of approach coping. Although this method of measuring approach coping has been utilized widely in other studies, it may have limited both our ability to fully assess the impact of approach coping and the robustness of its associations with other model variables. This is especially significant given that emotion-focused coping would likely be particularly relevant to the affective experience of trauma-related shame. Further research assessing both problem-focused and emotion-focused methods of coping is needed before conclusions concerning the role of approach coping in the shame-PTSD relationship can be drawn.

Although our findings offer a novel contribution to the literature on trauma-related shame and PTSD symptom severity, our study is not without limitations. Perhaps most importantly, our data were cross-sectional in nature, which precludes conclusions concerning temporality or causality in our model. As such, it is possible that the sequential order put forth in our model is correct in concluding that trauma-related shame leads to increased avoidance coping, which in turn leads to more severe PTSD symptoms; however, it remains possible that PTSD symptoms may lead to increased avoidance coping, which may, in turn, lead to greater levels of trauma-related shame. Future research employing a prospective design would be necessary to more fully understand the temporal order – and potentially the context – of these variables.

In addition, participants in our sample endorsed relatively low utilization of both approach and avoidance coping strategies relative to the possible range of values on the Brief COPE (Carver, 1997). Although we found significant correlations between both approach and avoidance coping and PTSD symptoms, use of avoidance coping strategies was particularly low, with the mean avoidance coping score falling short of the scale point corresponding to using avoidance strategies “a little bit” (Carver, 1997). Given extensive previous research documenting a strong association between experience with interpersonal trauma and greater use of avoidance coping methods (e.g., Krause et al., 2008; Ullman et al., 2013), the relatively low endorsement of avoidance coping among our sample is noteworthy. Although the reasons for this discrepancy remain unclear, it is possible that the low avoidance coping exhibited within our sample may be reflective of the types of coping assessed. For example, participants may have, in fact, been utilizing more avoidance coping strategies that were simply not assessed in the present study. Alternatively, it is possible that our sample simply utilized fewer avoidance coping techniques than the samples assessed in previous research or underreported their use of these strategies due to the retrospective nature of their reports (e.g., Stone et al., 1998). Additionally, it should be noted that little research has directly evaluated the utility of the Brief COPE in assessing approach and avoidance coping specifically, limiting knowledge concerning the psychometric properties of the Brief COPE when implemented for this purpose. Though the present study contributes to the limited literature using the Brief COPE to evaluate approach and avoidance coping, future work may benefit from utilizing measures that have better established psychometric properties when examining approach and avoidance coping specifically (e.g., Coping Strategies Inventory [Tobin, Holroyd, Reynolds, & Wigal, 1989], Ways of Coping Checklist [Vitaliano, Russo, Carr, Maiuro, & Becker, 1985]). Finally, it is not clear whether these findings would generalize to other trauma-exposed populations as the study at hand specifically recruited individuals with a history of interpersonal trauma. As a result, further research would be warranted to determine whether our findings generalize to a broader range of individuals exposed to trauma.

In spite of its limitations, the present study has several potential clinical implications. First, our findings suggest that interventions addressing PTSD symptoms among those experiencing trauma-related shame might benefit from targeting and reducing avoidance behaviors; however, these findings would need to be investigated prospectively before such a conclusion can be more substantially supported. Furthermore, these findings underscore the importance of evaluating and monitoring negative affect – in this case, trauma-related shame – in clinical settings when treating those who have experienced interpersonal trauma.

Taken together, our findings provide preliminary support for the notion that avoidance coping partially accounts for the association between trauma-related shame and PTSD symptoms among those with a history of interpersonal trauma. Such a finding is particularly significant given that very little is presently known about the factors that might be contributing to the shame-PTSD association, and no known previous work had examined the role of coping specifically in the shame-PTSD relationship. As a result, these findings contribute to a growing body of literature evaluating the role of shame in relation to negative trauma-related outcomes.

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