International Journal of Psychology and

Psychological Therapy
ISSN: 1577-7057
riptp@ual.es
Universidad de Almería
España

Cunha, Marina; Matos, Marcela; Faria, Daniela; Zagalo, Sofia

Shame Memories and Psychopathology in Adolescence: The Mediator Effect of Shame
International Journal of Psychology and Psychological Therapy, vol. 12, núm. 2, 2012, pp. 203-218
Universidad de Almería
Almería, España

Available in: http://www.redalyc.org/articulo.oa?id=56023336006

How to cite
Complete issue
Scientific Information System
More information about this article Network of Scientific Journals from Latin America, the Caribbean, Spain and Portugal
Journal's homepage in redalyc.org Non-profit academic project, developed under the open access initiative
International Journal of Psychology & Psychological Therapy, 12, 2, 203-218, 2012
Printed in Spain. All rights reserved. Copyright © 2012 AAC

Shame Memories and Psychopathology in Adolescence:

The Mediator Effect of Shame
Marina Cunha
Instituto Superior Miguel Torga, Coimbra
Cognitive-Behavioural Research Centre (CINEICC), University of Coimbra, Portugal
Marcela Matos*
Cognitive-Behavioural Research Centre (CINEICC), University of Coimbra, Portugal
Daniela Faria
Sofia Zagalo
Instituto Superior Miguel Torga, Coimbra, Portugal

Abstract
Research on shame and shame memories and their impact on psychopathology is scarce in
adolescence. This study explored the relationships among these variables in this developmental
period and tested a mediator model in which current shame feelings (external and internal
shame) were predicted to be mediators between shame memories traumatic and centrality
features and depressive and anxiety symptoms. Three hundred and fifty four adolescents
were assessed on measures of shame traumatic memory, centrality of shame memory,
external shame, internal shame and depression and anxiety symptoms. Path analysis results
showed that current feelings of external and internal shame fully mediated the effect of
centrality of shame memory on depression and anxiety symptoms and partially mediated the
effect of shame traumatic memory on these psychopathological indicators. These findings
emphasise the role of external and internal shame on how shame experiences that become
traumatic and central memories to self-identity impact on psychopathology, validating the
biopsychosocial model of shame in adolescence. In addition, our study may contribute to
develop clinical assessment and intervention with adolescents.
Key words: external shame, internal shame, shame memory, depression, anxiety, adolescents.

The transition into adolescence is marked by a significant rise in the prevalence

of mental health problems, namely depression (Angold & Rutter, 1992; Cole, Tram,
Martin, Hoffman, Ruiz, MJacquez, & Maschman, 2002; Fleming, Offord, & Boyle,
1989) and anxiety (Kashany & Orvaschel, 1990).
This increased vulnerability to emotional difficulties may be related to the variety
of physiological, psychological, relational and environmental changes that characterize
the transitional period that is adolescence. These developmental changes encompass
complex models of self and others, the formation of novel and autonomous self-identity,
concerns with peer-group relationships and the structuring of new peer group identities,
and the decrease of parents influence along with the increased use of peers as sources
of support, values and sense of belonging (Allen & Land, 1999; Gilbert & Irons, 2009;
*
Correspondence concerning this article should be addressed to: Marcela Matos, CINEICC, Faculdade de Psicologia e
Ciências da Educação, Universidade de Coimbra, Rua do Colégio Novo, Apartado 6153, 3001-802 Coimbra, Portugal.
E-mail: marcela.s.matos@gmail.com.
204 Cunha, Matos, Faria & Zagalo

McLean, 2005; McLean, Breen, & Fournier, 2010; Steinberg, 2002; Wolfe & Mash,
2006). Hence, in adolescence, there is a heightened focus on self-other evaluations
and competition with each other for acceptance, approval and status (Wolfe, Lennox,
& Cutler, 1986). Such concerns may render one more vulnerable to difficulties with
self-consciousness, self-presentation, fear of rejection and being assigned an unwanted
and inferior social rank position, all of which are linked to the experience of shame
(Gilbert & Irons, 2009).
Numerous theoretical accounts converge on the notion that shame is a multifaceted
self-conscious emotion related to a self-focused and self-evaluative experience of the self
(e.g., as inferior, inadequate, flawed, powerless; Kaufman, 1989; Lewis, 1971; Tangney
& Dearing, 2002; Tangney & Fisher, 1995; Tracy & Robins, 2004). However, shame is
fundamentally a socially-focused emotion, linked to the experience of having negative
aspects of the self exposed (Lewis, 1992, 2003), and to a sense of self as negatively
felt (e.g., contempt, anger, ridicule) and judged (e.g., as defective, inferior, incompetent)
by others (Gilbert, 1992, 1998, 2002).
The idea that shame is specifically social, since it has to arise in the social
arenas, has been developed by Gilbert in an integrative and evolutionary perspective -the
biopsychosocial model of shame (Gilbert, 1998, 2002, 2007). In light of this approach,
shame derives from human’s innate motives for attachment (Bowlby, 1969/1982, 1973;
Cassidy & Shaver, 1999), group belonging (Baumeister & Leary, 1995) and concern
with one’s relative social place (Gilbert, 1992, 2000). In addition, a set of unfolding
cognitive competencies for social understanding (e.g., theory of mind, Byrne, 1995;
mentalizing, Liotti & Gilbert, 2011) and for self-conscious awareness (Lewis, 2003;
Tracy & Robins, 2004) mature as we grow, in order to monitor self-in-relationship-to-
others, and impact on social behavior and self-evaluations (Baldwin, 2005; Gilbert, 2007).
These cognitive abilities evolved to make us highly sensitive, focused and responsive to
what others think and feel about the self, since human survival, prospering and welfare
greatly depend on being able to create desirable images of the self in the mind of the
others. In other words, to be seen as an attractive social agent (e.g., to be valued,
accepted, loved, nurtured by others) increases the chances of engaging others in the
co-creation of advantageous social roles (e.g., friend, lover, ally, team member). Thus,
to be loved, valued and chosen by others for important social roles, influences brain
maturation and affect regulation, fostering feelings of safeness and connectedness and
toning down distress in face of threats. In contrast, to be seen as an unattractive social
agent (e.g., being criticized, ridiculed, rejected, abused), compromises effective emotion
regulation, undermines the co-construction of favorable social roles and triggers threat
related responses (Ectoff, 1999; Gilbert, 1989, 1992, 1997, 2007; Gilbert & Irons, 2009).
In this context, shame arises in the dynamics of this competition for social
attractiveness, emerging from our evolved cognitive competencies for processing social
and self related information. Hence, shame acts as a warning signal that one is unable
to create positive feelings in others, and thus, exists negatively in their minds (e.g., as
boring, inferior, inadequate, powerless), standing at risk of being rejected, excluded,
marginalized, attacked or persecuted (Gilbert, 1997, 2002, 2003 2007; Gilbert & Irons,
2009). Shame has then evolved as a strategy to keep the self safe from possible attacks

© International Journal of Psychology & Psychological Therapy, 2012, 12, 2 http://www. ijpsy. com
 Shame and Psychopathology in Adolescence 205

and rejection form others, by triggering self-monitoring and self-blaming and defensive
submissive responses.
When one experiences the self as someone with negative qualities, or lack of
positive ones, in the eyes of the others, this can activate what Gilbert (1997, 1998, 2003;
Gilbert & Irons, 2009) defined as external shame. In external shame, one’s attention
and cognitive processing are attuned outwardly, to what is going on in the mind of the
other about the self, and one’s behavior might be orientated towards trying to positively
influence how others see the self (e.g., by submitting, displaying desirable qualities,
try to please others).
According to this model, this experience of the other as a threat to self and
self-identity can prompt externalizing (e.g., anger, aggression) or internalizing (e.g.
submissive withdrawing) defenses. Shame can therefore be internalized in that one may
start to identify with the mind of the other and engage in negative self-evaluations and
feelings, for purposes of restoring one’s image and protect the self against rejection or
attacks from others (Gilbert, 1998, 2003; Gilbert & Irons, 2009). Internal shame is then
when one experiences the self as globally flawed, inadequate, unattractive, undesired or
bad, with one’s attention and processing directed inwardly, to the inner landscapes of
the self (e.g., emotions, personal characteristic, behaviour; Gilbert, 2003, 2007; Gilbert
& Irons, 2009; Tangney & Dearing, 2002). Typically, shame experiences involve both
externally and internally focused shame, fueling each other. Still, proneness to experience
one type rather than the other in a given shame episode may vary according to factors,
such as early history of shaming experiences or the developmental period.
Although external and internal shame have consistently been associated with
the development and maintenance of mental health problems in adults, particularly
depression (Andrews, Qian, & Valentine, 2002; Ashby, Rice, & Martin, 2006; Cheung,
Gilbert & Irons, 2004; Matos, Pinto-Gouveia, & Duarte, 2011a, 2011b; Tangney, Stuewig,
& Mashek, 2007; Thompson & Berenbaum, 2006; for a review see, Kim, Thibodeau,
& Jorgensen, 2011) and anxiety (Matos et al., 2011a, 2011b; Pinto-Gouveia & Matos,
2011; Tangney, Wagner, & Gramzow, 1992), research on these two facets of shame in
adolescence remains scant.
Since childhood and throughout life, shame experiences occur in specific
interactions within the family environment or in wider social groups, which define what
is perceived as attractive, belonging, and accepted or, on the contrary, as unattractive,
rejected and outsider (Gilbert, 1998, 2002, 2007). The early precursors of shame take
place in adverse rearing interactions within the family, in form of parental criticism,
put-down, rejection, sibling favoritism (Gilbert, Allan & Goss, 1996; Tangney & Dearing,
2002), neglect (Claesson & Sohlberg, 2002), threat and submission (Gilbert, Cheung,
Grandfield, Campey, & Irons, 2003) and verbal, physical and sexual abuse (Andrews,
1998, 2002; Feiring, Taska, & Lewis, 2002; Stuewig & McCloskey, 2005; Teicher, Samson,
Polcari, & McGreenery, 2006), which elevate vulnerability to psychopathology. With the
transition into adolescence, the social world focus shifts to peer-group relationships, and
adolescents become more perceptive of the emotions and images they are creating in the
minds of their peers, opening up the potential to experience shame in this domain. So,
being seen as unattractive in this social realm may result in peer rejection, exclusion,

http://www. ijpsy. com © International Journal of Psychology & Psychological Therapy, 2012, 12, 2
206 Cunha, Matos, Faria & Zagalo

bullying, teasing or discrimination, which are known to be linked to psychological

problems (Gilbert & Irons, 2009; Hawker & Boulton, 2000; Pinel, 1999).
In this sense, early shame episodes entail major threat to the social self and
self-identity. Recent research has indeed found that adult’s recollections of shame
experiences from childhood and adolescence can function as traumatic memories,
involving intrusions, hyperarousal symptoms and strong emotional avoidance (Matos
& Pinto-Gouveia, 2010, 2011a). These threat memories can texture the whole sense of
self and become central to self-identity, structure one’s life narrative, forming a highly
available reference point to attribute meaning to past, current and future experiences
(Matos & Pinto-Gouveia, 2011b; Pinto-Gouveia & Matos, 2011). Also, shame traumatic
and central memories were found to be related to increased feelings of external and
internal shame in adulthood and greater depression, anxiety, stress, social anxiety
and paranoid symptoms (Matos & Pinto-Gouveia, 2010, 2011a, 2011b; Matos, Pinto-
Gouveia & Duarte, 2011c; Matos, Pinto-Gouveia, & Gilbert, 2011; Pinto-Gouveia &
Matos, 2011). In another study, Matos, Pinto-Gouveia and Duarte (2011d) examined the
mediator effect of shame on the relationships between shame memories and memories
of safeness and warmth from childhood and adolescence and depressive symptoms in
adults. Results established that early memories of shame and lack of safeness influence
upon depression was fully through their effect upon internal shame, whereas external
shame did not mediate these linkages.
In adolescence, however, research on shame feelings and memories is scarce. A
study tracking the trajectory of self-conscious emotions across the life span reported
that shame is greater in adolescence, decreasing into middle adulthood, and is negatively
related to psychological well-being throughout life (Orth, Robins, & Soto, 2010).
Furthermore, shame has been linked to poorer mental health, such as depression, in
youth (Reimer, 1996; Rubeis & Hollenstein, 2009) and shaming experiences have been
found to play a crucial role in adolescents’ health and well-being (Äslund, Nilsson,
Starrin, & Sjöberg, 2007; Reimer, 1996). In another study, negative social comparison
and submissive behavior (two social rank variables related to shame) were found to
mediate the association between insecure attachment and anxiety and depression (Irons
& Gilbert, 2005).
Even though there is strong empirical support for the link between early memories
of shame, and later vulnerability to shame and psychopathology in adults, these associations
have never been explored in an adolescent’s sample. Furthermore, given the crucial role
shame plays in the formation of one’s sense of self and self-identity as a social agent
(Gilbert, 1998, 2007; Lewis, 1992; Tangney & Dearing, 2002; Tracy & Robins, 2004),
one should expect this emotion to have a significant impact on poor psychological
adjustment indicators in this developmental period. In addition, the way an adolescent
experiences the others as relating to the self is key to shame in this period and may
become associated with adolescents’ maturing sense of self (Gilbert & Irons, 2009; Lewis,
2003). On the other hand, adolescence is when individuals engage in autobiographical
reasoning processes and begin to make connections between the self and past events. In
fact, recent research has shown that it is in adolescence that personal memories become
integrated in one’s life narrative and self-identity (McLean, 2005, 2008; McLean et

© International Journal of Psychology & Psychological Therapy, 2012, 12, 2 http://www. ijpsy. com
 Shame and Psychopathology in Adolescence 207

al., 2010; McLean & Thorne, 2003; Thorne, McLean, & Lawrence, 2004). Thus, a key
research question is how shame experiences come to be structured as traumatic and
central memories to adolescents’ identity and life story, forming the basis or reinforcing
internal working models of self (e.g., as worthy, attractive or unworthy and unattractive)
and others (e.g., as supportive and accepting or threatening or rejecting), translate into
shame feelings and elevate vulnerability to emotional psychological problems (Baldwin
& Dandeneau, 2005; Matos & Pinto-Gouveia, 2011a; Mikulincer & Shaver, 2004, 2005).
Therefore, the current study built upon prior research using adult samples and
sought out to answer this question exploring the relationship between shame traumatic
memory, centrality of shame memory, external and internal shame and symptoms of
depression and anxiety in a sample of adolescents. Taken together the aforementioned
theoretical and empirical accounts, we hypothesize that adolescents whose shame
memories are regarded as more traumatic and central to identity and life story would
score higher in external and internal shame and show greater levels of depression and
anxiety. We further expect external and internal shame to be strongly linked to depressive
and anxiety symptoms. Moreover, the primary aim of this study was to test the mediator
effect of current feelings of external and internal shame on the relationship between
shame traumatic memory and centrality of shame memory and depression and anxiety
symptoms. Based upon past research and the abovementioned conceptualizations, we
predict that adolescent’s shame traumatic and central memories impact upon depressive
and anxiety symptoms through their effect upon feelings of external and internal shame.

 
Figure 1. The theoretical model.

Method

Participants and Procedure

Three hundred and fifty four adolescents (157 boys and 197 girls) from 7th to
12th grade (years of education mean= 9.26, SD 1.61) completed a series of self-report

http://www. ijpsy. com © International Journal of Psychology & Psychological Therapy, 2012, 12, 2
208 Cunha, Matos, Faria & Zagalo

questionnaires. The mean age was 15 (SD= 1.78) years old, ranging from 12 to 18 and
no gender differences were found concerning age [t (352)= .180, p= .857].
This adolescents’ sample was collected from public schools in the district of
Coimbra, Portugal. Ethics approval was granted by the Head Teacher of the school and
parents were informed on the goals of the research and gave their consent. After given
a brief description on the purpose of the study and explained that their cooperation was
voluntary and their answers were anonymous and confidential, all adolescents completed
the measures at the beginning of a class at the same time and order that the rest of
their classmates.

Measures
Priming for the Shame Memory. Before completing the measures, participants were given
a brief introduction on the concept of shame and were asked to recall a significant
and stressful shame experience from their childhood or adolescence. Afterwards they
were instructed to answer the two shame memory related questionnaires (described
below) based on that experience. This adjustment in the instructions has been made
in other studies (Matos & Pinto-Gouveia, 2010; Pinto-Gouveia & Matos, 2011) and
it doesn’t seem to affect the validity of this measure, since the items’ content is well
suited for both instructions.
Centrality of Event Scale (CES; Berntsen & Rubin, 2006; Portuguese version by Matos,
Pinto-Gouveia, & Gomes, 2010) assesses the extent to which a memory for a stressful
event (in this case a shame experience reported by each participant) forms a reference
point for personal identity and to attribution of meaning to other experiences in a person’s
life. This self-report questionnaire consists of 20 items, rated on 5-point Likert scale
(1-5), that measure three interdependent characteristics of a highly negative emotional
event that load on to a single underlying factor: the extent to which the event is a
central component of one’s personal identity (e.g., “I feel that this event has become
part of my identity.”), is viewed as a landmark in one’s life story (e.g., “I feel that
this event has become a central part of my life story.”) and acts as a reference point
for inferences and attributions in everyday life (e.g., “This event has coloured the
way I think and feel about other experiences.”). In its original study and Portuguese
version, CES showed sound psychometric properties with a high internal consistency
(Cronbach α= .94 and .96 respectively). Cronbach’ alpha for this measure in the current
study is given in Table 1.
Impact of Event Scale-Revised (IES-R; Weiss & Marmar, 1997; Portuguese version by Matos,
Pinto-Gouveia, & Martins, 2010) is a self-report instrument designed to measure current
subjective distress for any specific life event and, specifically in this study, in relation
to the shame memory nominated by the participants. This scale has 22 items rated on
a 5-point Likert scale (0-4). The IES-R is composed by three subscales that measure
the three main characteristics of traumatic memories: avoidance (e.g., “I stayed away
from reminders of it”), intrusion (e.g., “Any reminder brought back feelings about it”)
and hyperarousal (e.g., “I was jumpy and easily startled”) that parallel the DSM-IV
criteria for PTSD. In the original study, Cronbach alphas of the subscales ranged from
.87 to .92 for intrusion, .84 to .86 for avoidance and .79 to .90 for hyperarousal (Weiss
& Marmar, 1997). The Portuguese version revealed a one-dimensional structure with
sound psychometric properties, with a Cronbach’ alpha of .96 (Matos, Pinto-Gouveia,
& Martins, 2010). Cronbach’ alpha for this measure in this study is shown in Table 1.
Other As Shamer (OAS; Goss, Gilbert, & Allan, 1994; Portuguese version by Matos,
Pinto-Gouveia, & Duarte, 2011a) is a 18 item scale measuring external shame (global
judgements of how people think others view them). Respondents rate on a 5-point

© International Journal of Psychology & Psychological Therapy, 2012, 12, 2 http://www. ijpsy. com
 Shame and Psychopathology in Adolescence 209

Likert scale (0–4) the frequency of their feelings and experiences, for example, ‘‘I
feel other people see me as not quite good enough’’ and ‘‘I think that other people
look down on me’’. Scores can range from 0 to 72 with higher scores on this scale
indicative of higher external shame. A Cronbach alpha of .92 was reported in the
original study of this scale Goss et al. (1994). The Cronbach alpha for the present
study is presented in Table 1.
Internalized Shame Scale (ISS; Cook, 1994, 2001; Portuguese version by Matos, Pinto-
Gouveia, & Duarte, 2011b) comprises a 24-item measure of internal shame, consisting
of negatively worded items (e.g., “Compared with other people, I feel like I somehow
never measure up”) assessing the frequency in which people experience feelings of
shame and a 6-item self-esteem scale consisting of positively worded items (e.g., “All
in all, I am inclined to feel that I am a success”) assessing self-esteem. All of the
items are rated on a scale of “0,” meaning “never,” to “4,” meaning “almost always.”
The shame subscale items were based on phenomenological descriptions of shame
feelings. In this study, only the shame subscale was used as a measure of internal
shame. Previous studies (Cook, 1996) have reported test–retest correlations of .84
and .69, respectively, and have reported good convergent and divergent validity. The
internal consistency of ISS shame subscale is reported in Table 1.
Depression, Anxiety and Stress Scale (DASS-21; Lovibond & Lovibond, 1995; Portuguese
version by Pais-Ribeiro, Honrado & Leal, 2004) is a self-report measure composed of
42 items and designed to assess three dimensions of psychopathological symptoms:
depression, anxiety and stress. The items indicate negative emotional symptoms and
are rated on a 4-point Likert scale (0-3). On the original version, Lovibond and
Lovibond (1995) found the subscales to have high internal consistency (Depression
subscale Cronbach’s α= .91; Anxiety subscale Cronbach’s α= .84; Stress subscale
Cronbach’s α= .90). In the present study, only the Depression and Anxiety subscales
will be considered. Cronbach alpha for this subscale in this study is shown in Table 1.

Data analysis

Data analyses were carried out using PASW (v. 18 SPSS) and path analyses were
estimated in AMOS (v. 18, SPSS).
Pearson correlation coefficients were performed to explore the association between
shame memory variables, external and internal shame and depressive and anxiety
symptoms (Cohen, Cohen, West & Aiken, 2003).
A mediational study was then conducted in which we tested whether external
shame (OAS) and internal shame (ISS) (mediator variables) mediated the relationship
between centrality of shame memory (CES) and shame traumatic memory (IES-R)
(independent, exogenous variables) and depression and anxiety (DASS-21 Depression
and Anxiety subscales) (dependent, endogenous variables).
A path analysis was carried out to test for the mediator effects described above.
This technique is a special case of structural equation modeling (SEM) and considers
hypothetic causal relations between variables that have already been defined. A Maximum
Likehood method was used to evaluate the regression coefficients significance. SEM
procedure estimates the optimal effect of one set of variables on another set of variables
in the same equation, controlling for error (Byrne, 2010; Kline, 2005). Multivariate
outliers were screened using Mahalanobis squared distance (D2) method and uni and
multivariate normality was assessed by skewness and kurtosis coefficients. There
was no severe violation of normal distribution (|Sk|<3 and |Ku|<8-10; Kline, 2005).
http://www. ijpsy. com © International Journal of Psychology & Psychological Therapy, 2012, 12, 2
210 Cunha, Matos, Faria & Zagalo

The significance of direct, indirect and total effects was assessed using χ2 tests (Kline,
2005). Bootstrapping resampling method was further used to test the significance of the
meditational paths, using 1000 bootstrap samples and 95% confidence intervals (CIs;
Kline, 2005). Effects with p <.050 were considered statistically significant.

Results

The means, standard deviations and Cronbach’ alphas of the variables studied are
reported in Table 1. All scales showed high internal consistency. In comparison to adult
samples, the means and standard deviations for shame memories and shame variables
are generally higher (Matos & Pinto-Gouveia, 2010; Matos, Pinto-Gouveia, & Duarte,
2011a, 2011b). In relation to psychopathology, similar means for depression and anxiety
subscales were found in studies with adolescent samples (Pinto, 2011).
Pearson product-moment correlations for all variables are reported in Table
1. Centrality of shame memory and shame traumatic memory were significantly and
positively correlated with each other and with depression. Centrality of shame memory
revealed positive moderate correlations with external and internal shame as well as with
depression and anxiety symptoms. In turn, shame traumatic memory was positively and
strongly linked to external and internal shame and to depression and anxiety. External
and internal shame showed positive and strong correlations with psychopathology
variables and with each other.
Given the previous findings and the proposed hypotheses, we intended to test
whether external and internal shame mediated the effect of centrality of shame memory
and shame traumatic memory on depressive and anxiety symptoms.
The hypothesized model (Figure 1) was tested through a fully saturated model
(i.e. zero degrees of freedom), consisting of 27 parameters. Given that fully saturated
models always produce a perfect fit to the data, model fit indices were neither examined
nor reported. The model explained 59% of depression and 56% of anxiety variances. In
this model all paths were statistically significant with the exception of the direct effect of
centrality of shame memory on depression (bCES= .025; SEb= .013; Z= 1.944; p= .052;
bCES= .081). Thus, this non significant path was excluded and the model recalculated. In

Table 1. Means (M), Standard Deviations (SD), Cronbach’ alphas (α) and Intercorrelation
scores on self-report measures (N = 354).
Measure M SD α CES IES-R OAS ISS Depression
CES 51.78 18.35 .95 -
IES-R 4.75 2.27 .94 .47 -
OAS 25.05 14.78 .95 .53 .62 -
ISS 43.72 20.58 .95 .51 .65 .77 -
Depression 7.42 5.75 .90 .49 .62 .69 .71 -
Anxiety 6.38 5.39 .88 .48 .65 .68 .64 .82
Note: All coefficients are significant at p <.001; CES= Centrality of shame memories; IES-R= Shame traumatic memory;
OAS= External shame; ISS= Internal shame; Depression= DASS-21 depression subscale; Anxiety= DASS-21 anxiety
subscale.

© International Journal of Psychology & Psychological Therapy, 2012, 12, 2 http://www. ijpsy. com
 Shame and Psychopathology in Adolescence 211

this second model the direct effect of centrality of shame memory on anxiety (bCES= .011;
SEb= .010; Z= 1.136; p= .256; bCES= .039) emerged as the only non significant path.
For this reason, this non significant path was further removed and the model
recalculated (Figure 2). In the evaluation of the final adjusted model, we found a very
good model fit with a non significant chi-square of 5.034 (p= .081). Besides, the analysis
of well-known and recommended goodness of fit indices (Kline, 2005) indicated an
excellent model fit (CMIN/DF= 2.517; CFI= .998; TLI= .984; NFI= .997; RMSEA= .066).
All the paths were statistically significant and the significance of indirect mediational
paths was further confirmed using bootstrap resampling method. The model accounted
for 58% of depression and 56% of anxiety variances.
In regard to depression, indirect mediational test results indicated that centrality
of shame memory (CES) predicted greater depression fully through heightened feelings
of external (OAS) and internal shame (ISS) (bCES= .178, 95% CI= .120 to .244). Shame
traumatic memory (IES-R) predicted elevated depression partially through increased
external (OAS) and internal shame (ISS) (bIES-R= .317, 95% CI= .253 to .386), but also
revealed a direct effect of .330.
For anxiety, indirect meditational tests showed that centrality of shame memory
(CES) indirectly predicted increased anxiety symptoms fully through greater feelings of
external (OAS) and internal shame (ISS) (bCES= .148, 95% CI= .092 to .208). Shame
traumatic memory (IES-R) predicted elevated anxiety partially through increased external
(OAS) and internal shame (ISS) (bIES-R= .246 (95% CI= .186 to .309) and showed a
significant direct effect of .337. Figure 2 presents the mediation model with regression
coefficients standardized estimates and R2 for depression, anxiety, internal and external
shame.

 
Figure 2. Results of mediation path analysis showing the relationships among centrality of
shame memory (CES), shame traumatic memory (IES-R) depression and anxiety, having
external shame (OAS) and internal shame (ISS) as mediators, with standardised estimates
and square multiple correlations (N= 354).

http://www. ijpsy. com © International Journal of Psychology & Psychological Therapy, 2012, 12, 2
212 Cunha, Matos, Faria & Zagalo

In conclusion, these findings reveal that internal and external shame fully mediate
the effect of centrality of shame memory on depressive and anxiety symptoms and
partially mediate the effect of shame traumatic memory on these variables.

Discussion

The pathogenic nature of shame and early aversive experiences has been
established in several studies, mostly conducted in adult samples. Adolescence is marked
by foremost developmental changes and tasks, such as identity formation, establishing
friendships, group identification or emotional independence. These characteristics turn it
into a period of vulnerability to the impact of adverse experiences, in particular, shame
ones. Therefore, the present study aimed at investigating the relations among shame
memories traumatic and centrality features, external and internal shame and depressive
and anxiety symptoms in a sample of adolescents.
Consistent with prior research (Matos & Pinto-Gouveia, 2010, 2011a, 2011b; Pinto-
Gouveia & Matos, 2011) and our hypothesis, correlation analyses results showed that
shame traumatic memory and centrality of shame memory were moderately to strongly
associated with measures of shame (external and internal) and depression and anxiety
symptoms. The same is to say that adolescents whose early shame experiences operate
as traumatic memories, eliciting intrusions, hyper arousal and avoidance symptoms,
and who regard these shame events as key to personal identity and as turning points
in their life story, tend to develop a sense of self as existing negatively in the eyes of
the others (i.e., external shame) and in their own eyes (i.e., internal shame) and present
increased negative emotional states (i.e., depression and anxiety). In addition, external and
internal shame were found to be strongly correlated with depression and anxiety. These
findings are in line with studies conducted in adult samples (Matos et al., 2011a, 2011b;
for a review see, Kim et al., 2011). By distinguishing between external and internal
shame, our study extends research in adolescence on the linkage between shame and
psychopathology (Irons & Gilbert, 2005; Reimer, 1996; Rubeis & Hollenstein, 2009).
However, the question remained as to the role of external and internal shame on
the relationship between shame traumatic memory and centrality of shame memory and
depression and anxiety symptoms. Thus this study tested a mediator model in which
we examined whether shame memories’ traumatic and centrality qualities impacted
upon depression and anxiety through their effect upon current feelings of external and
internal shame. In accordance with our prediction, path analysis results indicated that
internal and external shame fully mediate the effect of centrality of shame memory on
depression and anxiety and partially mediate the effect of shame traumatic memory
on these psychopathological indicators. This means that shame memories that become
central to personal identity and life story impact on depressive symptoms through their
influence on generating feelings and beliefs that one exists negatively in the mind of
the others (e.g. as inferior, worthless, unattractive) and on perceptions of the self as
inferior, inadequate, defective or unlovable. In turn, the impact of shame memories that

© International Journal of Psychology & Psychological Therapy, 2012, 12, 2 http://www. ijpsy. com
 Shame and Psychopathology in Adolescence 213

operate as traumatic ones (e.g. with intrusion, hyperarousal and avoidance symptoms)
on depression is only partially explained by their influence on current feelings of the
self as flawed, undesirable, inadequate or bad in its own eyes and in the eyes of the
others. In addition, the impact of shame memories that are key to adolescent’s identity
on anxiety operates through their influence on fostering current shame feelings focused
on how one exists in the mind of the others and on negative self-evaluations and
feelings. Furthermore, the influence of early shame experiences that function as traumatic
memories on anxiety symptoms is in part explained by their impact on promoting a
sense of the self as existing negatively in one’s own eyes and for others. Noteworthy
is also the independent effect of shame traumatic memories on depressive and anxiety
symptoms, which is not fully explained by their effect on current feelings of shame.
These results can be understood in light of evolutionary biopsychosocial model
of shame (Gilbert, 1998, 2002, 2007). Shame experiences in early life, by acting as
conditioned emotional memories, may trigger intrusions, physiological arousal and
avoidance and become central to adolescents’ self-identity and life story, and thus
engender a sense of current threat to the (social) self, leaving one to feel inferior, flawed,
unlovable, undesired and alone. These feelings of inferiority and disconnectedness from
others seem to be constellated around a sense of self as negatively seen by others and
judged by the self, which in turn may render the adolescent more vulnerable to enter
defeat and threat emotional states when facing adverse life events. The present data are in
accordance with earlier work on shame memories, shame and psychopathology in adults
(Matos et al., 2011d), highlighting some distinctions that may be related to particular
features of this developmental stage. In particular, whereas in adults internal shame was
found to be the only mediator of shame memories and centrality features’ impact on
depression (Matos et al., 2011d), in adolescents both externally and internally focused
shame were significant mediators of shame memories and centrality features’ impact on
depression and anxiety, with external shame revealing the most expressive effect upon
these psychopathological indicators. A possible explanation for these results might be
related to the major developmental tasks of adolescence (e.g., establishing friendships,
group identification or emotional independence), which are especially orientated to the
others. In addition, the fact that self-identity is co-constructed in one’s interactions with
others and based on the experience of the self linked to how others view and respond
to the self might further help to make sense of this finding. This idea is consistent with
shame and attachment theories (Bowlby, 1969/1982; Cooley, 1902; Gilbert, 1998, 2002;
Kaufman, 1989; Kohut, 1977) proposing that the way we experience ourselves, that
is our identity, is mainly derived from how we feel we exist for others (i.e., external
shame). In adults, however and in accordance with Gilbert’s model of shame (1998, 2002,
2007), it might be that external shame (particularly relevant in adolescence) becomes
internalized as one grows older and self-identify is consolidated.
Furthermore, our findings are in line with the notion that personal memories
become part of personal identity and life story in adolescence (McLean, 2005; McLean
et al., 2010; MacLean & Thorne, 2003). Similarly to studies in adults (Matos & Pinto-
Gouveia, 2011a; Matos et al., 2011c), these data suggest that shame experiences can
function as traumatic and central memories to adolescents’ self-identity and influence

http://www. ijpsy. com © International Journal of Psychology & Psychological Therapy, 2012, 12, 2
214 Cunha, Matos, Faria & Zagalo

the formation of negative internal working models of self and others, thus increasing
proneness to feelings of shame and to emotional difficulties.
Some methodological limitations should be noted when interpreting our results.
First, the cross-sectional design of this study impairs the confidence in causal relations
between variables. Even so, the use of path analysis, a powerful statistical technique
based on structural equation modeling, enhances the strength in our conclusions. Another
limitation relates to the use of self-report data to assess shame memories, which may raise
some concerns regarding the influence of current emotional states on these recollections.
Still, not only studies have shown that retrospective recall data are generally reliable,
accurate and stable over time (Brewin, Andrews, & Gotlib, 1993), but also, the temporal
proximity to the experiences recalled in adolescence may enhance the accuracy and
reliability of the memories. Social desirability issues in using self-report questionnaires
might have influenced adolescents’ responses in shame and psychopathology measures.
Future research should attempt to overcome these limitations by, for instance, using
a prospective design and other assessment methods, such as structured interviews to
evaluate shame memories and shame (specifically, the Shame Experiences Interview,
Matos & Pinto-Gouveia, 2006).
Nevertheless, our study might have theoretical implications, validating the
biopsychosocial model of shame in adolescence (Gilbert & Irons, 2009). Besides, these
results highlight the clinical relevance of assessing and addressing shame and shame
memories when working with adolescents suffering from depression or anxiety, since
this can help to reduce current symptoms and to prevent future emotional problems
linked to these early shame experiences.

References

Allen JP & Land D (1999). Attachment in adolescence. In J Cassidy & P Shaver (Eds.), Handbook of
Attachment: Theory, Research and Clinical Applications (pp. 319-335). New York: Guilford Press.
Andrews B (1998). Shame and childhood abuse. In P Gilbert & B Andrews (Eds.), Shame: Interpersonal
Behavior, Psychopathology and Culture (pp. 176-190). New York: Oxford University Press.
Andrews B (2002). Body shame and abuse in childhood. In P Gilbert & J Miles (Eds.), Body Shame:
Conceptualisation, Research and Treatment (pp. 256-266). London: Routledge.
Andrews B, Qian M, & Valentine J (2002). Predicting depressive symptoms with a new measure of
shame: The experience of shame scale. The British Journal of Clinical Psychology, 41, 29-33.
Angold A & Rutter M (1992). Affects of age and pubertal status on depression in a large clinical sample.
Development and Psycholopathology, 4, 5-28.
Ashby J, Rice K, & Martin J (2006). Perfectionism, shame and depressive symptoms. Journal of
Counselling and Development, 84, 148-157.
Åslund C, Nilsson KW, Starrin B, & Sjöberg RL (2007).Shaming experiences and the association between
adolescent depression and psychosocial risk factors. European Child & Adolescent Psychiatry,16,
298-304. doi: 10.1007/s00787-006-0564-1.
Baldwin MW (2005). Interpersonal cognition. New York: Guilford Press.
Baldwin MW & Dandeneau SD (2005). Understanding and modifying the relational schemas underlying
insecurity. In MW Baldwin (Ed.), Interpersonal cognition (pp. 33-61). New York: Guilford.

© International Journal of Psychology & Psychological Therapy, 2012, 12, 2 http://www. ijpsy. com
 Shame and Psychopathology in Adolescence 215

Baumeister RF & Leary MR (1995). The need to belong: Desire for interpersonal attachments as a
fundamental human motivation. Psychological Bulletin, 117, 497-529.
Berntsen D & Rubin DC (2006). Centrality of Event Scale: A measure of integrating a trauma into one’s
identity and its relation to post-traumatic stress disorder symptoms. Behaviour Research and
Therapy, 44, 219-231.
Bowlby J (1969/1982). Attachment and loss, Vol. 1: Attachment. London: Hogarth Press.
Bowlby J (1973). Attachment and loss, Vol. 2: Separation. London: Hogarth Press.
Brewin C, Andrews B, & Gotlib I (1993). Psychopathology and early experience: a reappraisal of
retrospective reports. Psychological Bulletin, 113, 82-98.
Byrne BM (2010). Structural Equation Modelling with AMOS: Basic Concepts, Applications, and
Programming. (2nd ed.) New York: Routledge Academic.
Byrne RW (1995). The thinking ape. Oxford: Oxford University Press.
Cassidy J & Shaver PR (Eds.) (1999). Handbook of Attachment: Theory, Research and Clinical
Applications (pp. 115-140). New York: Guilford Press.
Cheung MSP, Gilbert P, & Irons C (2004). An exploration of shame, social rank and rumination in relation
to depression. Personality and Individual Differences, 36, 1143-1153.
Claesson K & Sohlberg S (2002). Internalized shame and early interactions characterized by indifference,
abandonment and rejection: Replicated findings. Clinical Psychology and Psychotherapy, 9,
277-284.
Cohen J, Cohen P, West S, & Aiken L (2003). Applied multiple regression/correlation analysis for the
behavioural sciences (3th ed.). New Jersey: Lawrence Erlbaum Associates.
Cole DA, Tram JM, Martin JM, Hoffman KB, Ruiz MD, Jacquez FM, & Maschman TL (2002). Individual
differences in the emergence of depressive symptoms in children and adolescents: A longitudinal
investigation of parent and child reports. Journal of Abnormal Psychology, 111, 156-165.
Cook DR (1994, 2001). Internalized shame scale: Technical manual. North Tonawanda, NY: Multi-
Health Systems, Inc.
Cooley CH (1902). Human Nature and the Social Order. New York, NY: Scribner’s.
Etcoff N (1999). Survival of the Prettiest: The Science of Beauty. New York, NY: Doubleday.
Feiring C, Taska L, & Lewis M (2002). Adjustment following sexual abuse discovery: the role of shame
and attributional style. Developmental Psychology, 38, 79-92.
Fleming IE, Offord DR, & Boyle MH (1989). Prevalence of childhood and adolescent depression in the
community: Ontario child health study. British Journal of Psychiatry, 155, 647-654.
Gilbert P (1989). Human Nature and Suffering. Hove: Lawrence Erlbaum Associates.
Gilbert P (1992). Depression: The Evolution of Powerlessness. London: Lawrence Erlbaum Associates.
Gilbert P (1997). The evolution of social attractiveness and its role in shame, humiliation, guilt and
therapy. British Journal of Medical Psychology, 70, 113-147.
Gilbert P (1998). What Is Shame? Some Core Issues and Controversies. In P Gilbert and B Andrews
(Eds.). Shame: Interpersonal Behaviour, Psychopathology and Culture (pp. 3-36). New York:
Oxford University Press.
Gilbert P (2000b). The relationship of shame, social anxiety and depression: the role of the evaluation
of social rank. Clinical Psychology and Psychotherapy, 7, 174-189.
Gilbert P (2002). Body Shame: A Biopsychosocial Conceptualisation and Overview, with Treatment
Implications. In P Gilbert & J Miles (Eds.). Body Shame: Conceptualisation, Research and
Treatment (pp. 3-54). London: Routledge.
Gilbert P (2003). Evolution, Social Roles and the Differences in Shame and Guilt. Social Research, 70,
1205-1230.
Gilbert P (2007). The evolution of shame as a marker for relationship security. In JL Tracy, RW Robins,
& JP Tangney (Eds.). The Self-Conscious Emotions: Theory and Research. (pp. 283-309). New

http://www. ijpsy. com © International Journal of Psychology & Psychological Therapy, 2012, 12, 2
216 Cunha, Matos, Faria & Zagalo

York: Guilford.
Gilbert P, Allan S, & Goss K (1996). Parental representations, shame, interpersonal problems, and
vulnerability to psychopathology. Clinical Psychology and Psychotherapy, 3, 23-34.
Gilbert P, Cheung M, Grandfield T, Campey F, & Irons C (2003). Recall of threat and submissiveness in
childhood: Development of a new scale and its relationship with depression, social comparison
and shame. Clinical Psychology and Psychotherapy, 10, 108-115.
Gilbert P & Irons C (2009). Shame, self-criticism, and self-compassion in adolescence. In N Allen (Ed.).
Psychopathology in Adolescence. Cambridge: Cambridge University Press.
Goss K, Gilbert P, & Allan S (1994). An exploration of shame measures I. The “Other as Shamer Scale”.
Personality and Individual Differences, 17, 713-717.
Hawker DS, & Boulton MJ (2000). Twenty years’ research on peer victimization and psychosocial
maltreatment: a meta-analytic review of cross sectional studies. Journal of Child Psychology
and Psychiatry and Allied Disciplines, 41, 441-455.
Irons C & Gilbert P (2005b). Evolved mechanisms in adolescent anxiety and depression symptoms: the
role of attachment and social rank systems. Journal of Adolescence, 28, 325-341.
Kashani JH & Orvaschel H (1990). A community study of anxiety in children and adolescents. American
Journal of Psychiatry, 147, 313-318.
Kaufman G (1989). The Psychology of Shame: Theory and Treatment of Shame-based Syndromes. New
York: Springer.
Kim S, Thibodeau R, & Jorgensen R (2011). Shame, guilt, and depressive symptoms: a meta-analytic
review. Psychological Bulletin, 137, 68-96.
Kline R (2005). Principles and practice of structural equation modelling (2th ed.). New York: The
Guilford Press.
Kohut H (1977). The Restoration of the Self. New York, NY: International Universities Press.
Lewis HB (1971). Shame and guilt in neurosis. New York: International Universities Press.
Lewis M (1992). Shame: The Exposed Self. New York: The Free Press.
Lewis M (2003). The role of the self in shame Social Research. An International Quarterly of the Social
Sciences, 70, 1181-1204.
Liotti G & Gilbert P (2011). Mentalizing, motivation, and social mentalities: Theoretical considerations
and implications for psychotherapy. Psychology and Psychotherapy: Theory, Research and
Practice, 84, 9-25. doi: 10.1348/147608310X520094.
Lovibond P & Lovibond H (1995). The structure of negative emotional states: Comparison of the
depression anxiety stress scales (DASS) with beck depressive and anxiety inventories. Behaviour
Research and Therapy, 3, 335-343.
Matos M & Pinto-Gouveia J (2006). The Shame Experiences Interview. Unpublished manuscript.
Matos M & Pinto-Gouveia J (2010). Shame as a Traumatic Memory. Clinical Psychology and
Psychotherapy, 17, 299-312. doi: 10.1002/cpp.659.
Matos M & Pinto-Gouveia J (2011a). Shamed by a parent or by others: The role of attachment in shame
memories relation to depression. Manuscript submitted for publication.
Matos M, & Pinto-Gouveia, J. (2011b). Shame memories that shape who we are: The moderator effect
of between shame and depression. Manuscript submitted for publication.
Matos M, Pinto-Gouveia J, & Duarte C (2011a). Other as Shamer: Versão portuguesa e propriedades
psicométricas de uma medida de vergonha externa. Manuscript submitted for publication.
Matos M, Pinto-Gouveia J, & Duarte C (2011b). When I don’t like myself: Psychometric properties of the
Portuguese version of the Internalized Shame Scale. Spanish Journal of Psychology. (In press)
Matos M, Pinto-Gouveia J, & Duarte C (2011c). Above and beyond emotional valence: The unique
contribution of the central and traumatic shame memories to psychopathology vulnerability.
Manuscript submitted for publication.

© International Journal of Psychology & Psychological Therapy, 2012, 12, 2 http://www. ijpsy. com
 Shame and Psychopathology in Adolescence 217

Matos M, Pinto-Gouveia J, & Duarte C (2011d). Internalizing early memories of shame and lack of
safeness and warmth: The mediating role of shame on depression. Manuscript submitted for
publication.
Matos M, Pinto-Gouveia J, & Gilbert P (2011). The effect of shame and shame memories on paranoid
ideation and social anxiety. Clinical psychology and Psychotherapy (In press).
Matos M, Pinto-Gouveia J, & Gomes P (2010). A Centralidade das Experiências de Vergonha: Estudo das
propriedades psicométricas da versão portuguesa da Escala da Centralidade do Acontecimento.
Psicologia, XXIV, 73-95.
Matos M, Pinto-Gouveia J, & Martins S (2010). Propriedades psicométricas da versão portuguesa da
Escala do Impacto do Acontecimento-Revista (IES-R). Psychologica. (In press).
McLean KC (2005). Late adolescent identity development: Narrative meaning-making and memory
telling. Developmental Psychology, 41, 683-691.
McLean KC (2008). Stories of the young and the old: Reflections on self-continuity. Developmental
Psychology, 44, 254-164.
McLean KC, Breen AV & Fournier MA (2010). Constructing the Self in Early, Middle, and Late
Adolescent Boys: Narrative Identity, Individuation, and Well-Being. Journal of Research on
Adolescence, 20, 166-187. doi: 10.1111/j.1532-7795.2009.00633.x.
McLean KC & Thorne A (2003). Late adolescents’ self-defining memories about relationships.
Developmental Psychology, 39, 635-645.
Mikulincer M & Shaver PR (2004). Security-based self-representations in adulthood: Contents and
processes. In WS Rholes & JA Simpson (Eds.), Adult attachment: Theory, research, and clinical
implications (pp. 159-195). New York: Guilford Press.
Mikulincer M & Shaver P (2005). Mental representations of attachment security: Theoretical foundations
for a positive social psychology. In MW Baldwin (Ed.), Interpersonal cognition (pp. 233-266).
New York: Guilford.
Orth U, Robins, RW, & Soto CJ (2010). Tracking the trajectory of shame, guilt, and pride across the life
span. Journal of Personality and Social Psychology, 99, 1061-1071.
Pais-Ribeiro J, Honrado A, & Leal I (2004). Contribuição para o estudo da adaptação portuguesa das
Escalas de Ansiedade Depressão e Stress de Lovibond e Lovibond. Psychologica, 36, 235-246.
Pinel EC (1999). Stigma consciousness: the psychological legacy of social stereotypes. Journal of
Personality and Social Psychology, 76, 114-128.
Pinto T (2011). Cyberbulling: Estudo da prevalência de comportamentos de cyberbulling e sua relação
com vivências de vergonha e estados emocionais negativos. Tese de mestrado, ISMT, Coimbra.
Pinto-Gouveia J & Matos M (2011). Can shame memories become a key to identity? The centrality of
shame memories predicts psychopathology. Applied Cognitive Psychology, 25, 281-290. doi:
10.1002/acp1689.
Reimer MS (1996). Sinking into the ground: The development and consequences of shame in adolescence.
Developmental Review, 16, 321-363.
Rubeis S & Hollenstein S (2009). Individual differences in shame and depressive symptoms during early
adolescence Personality and Individual Differences, 46, 477-482. doi:10.1016/j.paid.2008.11.019
Steinberg L (2002). Adolescence. Boston, MA: McGraw Hill.
Stuewig J & McCloskey L (2005). The impact of maltreatment on adolescent shame and guilt:
Psychological routes to depression and delinquency. Child Maltreatment, 10, 324-336.
Tangney JP & Dearing RL (2002). Shame and Guilt. New York: Guilford Press.
Tangney JP & Fischer KW (1995). The Self-Conscious Emotions: Shame, Guilt, Embarrassment, and
Pride. New York: Guilford Press.
Tangney J, Stuewig J, & Mashek D (2007). Moral emotions, moral cognitions, and moral behavior.
Annual Review of Psychology, 58, 345-372.

http://www. ijpsy. com © International Journal of Psychology & Psychological Therapy, 2012, 12, 2
218 Cunha, Matos, Faria & Zagalo

Tangney J, Wagner P, & Gramzow R (1992). Proneness to shame, proneness to guilt and psychopathology.
Journal of Abnormal Psychology, 101, 469-478.
Teicher MH, Samson JA, Polcari A, & McGreenery CE (2006). Sticks and stones and hurtful words:
relative effects of various forms of childhood maltreatment. American Journal of Psychiatry,
163, 993-1000.
Thorne A, McLean, KC, & Lawrence A (2004). When remembering is not enough: Reflecting on self-
defining events in late adolescence. Journal of Personality, 72, 513-542.
Tracy JL & Robins RW (2004). Putting the self into self-conscious emotions: A theoretical model.
Psychological Inquiry, 15, 103-125.
Thompson R & Berenbaum H (2006). Shame reactions to everyday dilemmas are associated with
depressive disorder. Cognitive Therapy and Research, 30, 415-425.
Weiss DS & Marmar CR (1997). The Impact of Event Scale-Revised. In JP Wilson & TM Keane (Eds.),
Assessing Psychological trauma and PTSD (pp. 399-411). New York: Guilford Press.
Wolfe, R.N., Lennox, R.D., & Cutler, B.L. (1986). Getting along and getting ahead: empirical support
for a theory of protective and acquisitive self-presentation. Journal of Social and Personality
Psychology, 50, 356-361.
Wolfe DA & Mash EJ (2006). Behavioral and Emotional Disorders in Adolescents. London: Guilford Press

Received, April 3, 2012

Final Acceptance, April 30, 2012

© International Journal of Psychology & Psychological Therapy, 2012, 12, 2 http://www. ijpsy. com