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thesis entitled
AN INVESTIGATION OF STIGMA AND SHAME IN HIV AND

HOMOSEXUALITY: AN AFFECT THEORY AND SHAME THEORY
PERSPECTIVE

presented by
JOSHUA MARCUS COHEN

has been accepted towards fulfillment
of the requirements for

Ph.D degree in Psychology

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0-7639 MS U i: an Ajﬁrmative Action/Equal Opportunity Institution

 

 

 

 

 

 

 

 

LIBRARY
Michigan State
University

 

 

 

PLACE IN RETURN BOX to remove this checkout from your record.
TO AVOID FINES return on or before date due.
MAY BE RECALLED with earlier due date if requested.

 

DATE DUE DATE DUE DATE DUE

 

APR [I 9 20,06

1216‘ 05

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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AN INVESTIGATION OF STIGMA AND SHAME 1N HIV
AND HOMOSEXUALITY: AN AFFECT THEORY AND SHAME THEORY
PERSPECTIVE
By

Joshua Marcus Cohen

A DISSERTATION

Submitted to
Michigan State University
in partial ﬁilﬁllment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY
Department of Psychology

2000

 

 

 

 

 

 

 

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ABSTRACT
AN INVESTIGATION OF STIGMA AND SHAME IN HIV AND
HOMOSEXUALITY: AN AFFECT THEORY AND SHAME THEORY
PERSPECTIVE
By

Joshua Marcus Cohen

Through the lens of Aﬂ‘ect Theory and Shame Theory, this study evaluated the
aﬂ‘ective reactions of college men when confronted with issues related to HIV infection
and homosexuality. In the study, 131 subjects completed a Demographic Questionnaire, a
Sexual Orientation Questionnaire, and a Health Status Questionnaire. Next, each subject
completed an Internalized Shame Scale (IS S) used to rate their own level of internalized
shame. Then each subject read one of four vignettes. The vignettes described _a male
college student who is either HIV+ and Homosexual, HIV+ and Heterosexual, has
Leukemia and is Homosexual, or has Leukemia and is Heterosexual. Next, subjects
completed a second Internalized Shame Scale, this time answering questions to describe
how the man in the vignette feels; this yielded projected-shame ratings. They also
completed an Aﬂ‘ect Inventory, again describing their projected feelings for the man in the
vignette. Finally, each subject wrote a short paragraph about their responses. Two
hypotheses were tested: Hypothesis One predicted a 3-Way Interaction between Disease,
Sexual Orientation, and ISS-scores, the Target of shame ratings Factor. Moreover, it was
predicted that the following rank order of responses would be produced: the largest

increase in shame scores between the IS S-self score and the ISS-projected score would be

 

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generated for the vignette describing HIV+ status and Homosexuality; the second largest
increase would be generated for the vignette describing HIV+ status and Heterosexuality;
the third largest increase would be generated for the vignette describing Leukemia and
Homosexuality; and the smallest increase would be generated for the vignette describing
Leukemia and Heterosexuality. The 3-Way Interaction was not signiﬁcant, although the
results did reveal a signiﬁcant Main Effect for Disease. Hypothesis Two predicted an
Interaction Effect on the Affect Inventory for Disease and Sexual Orientation. Here, it
was predicted that the highest scores would be generated on the “shame” sub-scale of the
Affect Inventory for vignettes describing HIV+ status and Homosexuality; second highest
for HIV + status and Heterosexuality; third highest for Leukemia and Homosexuality; and
the lowest for Leukemia and Heterosexuality. In order to test Hypothesis Two, a
Repeated Measure AN OVA and a MANOVA were computed. The 2-Way Interaction
was not signiﬁcant. The Affect Inventory was also analyzed using a Principal Components
Analysis, followed by an Exploratory Factor Analysis of the Principal Components
solution. The results revealed two factors and, overall, the Aﬁ‘ect Inventory was found to
have statistically sound construction. The discussion explored the Affect Inventory’s
construction, possible reasons for the non-signiﬁcant and signiﬁcant ﬁndings, ideas for

future research in this area, and the clinical implications of this research.

First, I dedicate my dissertation to my wife, Sandy Cohen.
Sandy has been my source of strength throughout graduate school,
providing the love, support, and encouragement I needed for survival.
She is the ﬁnest person I know, the love of my life, and the ultimate partner.

Second, I dedicate my dissertation to the participants of the “Men’s HIV+ Support
Group”of East Lansing, Michigan. Between 1996 and 1999, those men invited me to
share their experiences and allowed me to enter their lives and learn.
All of them will live in my heart and my memory forever.

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ACIG‘IOWLEDGMENTS

I would like to begin by thanking my family for their unwavering love and support.
Throughout my years of schooling they have never hesitated to provide me with the
assistance, love, and encouragement that I often needed. Whether living near or far from
one another, their warm thoughts were always felt. Thank you.

Next, I would like to thank Dr. Susan Frank for sharing her research expertise and
for serving as a committee member. Dr. Frank repeatedly went above and beyond the call
of duty, reading my proposal drafts and Oﬂ‘ering suggestions to improve the methodology
of this study. Her thoughtﬁil input ultimately improved this project’s feasibility.
Additionally, Dr. Frank spent many hours sharing her statistical expertise, without which
this project would have suﬂ‘ered many more setbacks and ﬁ'ustrations.

Next, I would like to extend heartfelt thanks to Dr. Bertram Karon and Dr.
Alexander Van Eye. Each of these committee members was available when theoretical
questions arose, and each oﬂ‘ered helpful suggestions at my proposal defense and
thoughtful comments at my ﬁnal oral defense. Their help and participation is greatly
appreciated.

I would also like to thank Mr. Charles Cook, a ﬁiend who helped collect data and
therefore supported my eﬂ‘orts in completing the dissertation. Without his persistence and
relentless approach to data collection this project may have lingered into eternity.

Finally, I owe an immeasurable debt of gratitude to Dr. Gersh Kaufman. Under his
tutelage for two years in practicum class, as Chairperson on my Guidance Committee,

Chairperson on two of my Competency projects, as well as the Chairperson on this

J

 

 

 

 

 

 

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With all I

 

Dissertation Committee, Dr. Kaufman has been my mentor in almost all aspects of my
training. Always available with a warm hug and positive encouragement, but never
avoiding the opportunity to guide with necessary constructive criticism, Dr. Kaufman is
the ultimate mentor. Without his guidance and support I would not have completed my
degree and would have missed the chance to continue doing therapy, my life’s dream.

With all my love and admiration, thank you Gersh.

 

 

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TABLE OF CONTENTS

LIST OF TABLES .................................................... x

CHAPTER 1: STATEMENT OF THE PROBLEM ........................... l
Stigma and Shame: The Nature of Societal Attitudes Toward

HIV/AIDS and Homosexuality ...................................... 4

Research on HIV/AIDS and Homosexuality: The Role of Stigma ............ 7

Grief and Loss Issues ...................................... 11

Psychoimmunology .................................. 12

Studies of HIV/AIDS and Psychological Disorders: Methodological
Problems and Conﬂicting Findings Signify the Need for a New Research

Paradigm ..................................................... 15
Signiﬁcant Research Findings ................................ 15
Non-Signiﬁcant Research Findings ............................ 22

Aﬂ‘ect Theory and Shame Theory: Early Formulations and

Later Theories Of Shame ......................................... 26
Aﬂ‘ect Theory ............................................ 29
Shame Theory ........................................... 32
Shame and HIV/AIDS ..................................... 35

CHAPTER 2: DESIGN OF THE CURRENT STUDY ........................ 37
Hypothesis One ................................................ 38
Hypothesis Two ................................................ 39

CHAPTER 3: METHOD .............................................. 40

Subjects ...................................................... 40

Materials ..................................................... 4O
Informed Consent ......................................... 41

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Demographic Information Questionnaire ........................ 41

Sexual Orientation Questionnaire ............................. 41
Current Health Status Questionnaire ........................... 42
Internalized Shame Scale ................................... 42

Affect Inventory .......................................... 44
Procedure .................................................... 46
Data Analysis ............................................ 47
General Statistical Procedures ............................... 47

Data Analysis for Hypothesis One ............................. 48

Data Analysis for the Affect Inventory and Hypothesis Two ......... 48
CHAPTER 4: RESULTS .............................................. 49
Demographic Information ........................................ 49
Results of Primary Predictions ..................................... 49
Results for Hypothesis One .................................. 49
Analysis of the Aﬂ‘ect Inventory & Results for Hypothesis Two ...... 50
CHAPTER 5: DISCUSSION ........................................... 53
Discussion of the Affect Inventory .................................. 53
Discussion of the Primary Prediction ................................ 55
Hypothesis One .......................................... 55
Unexpected Group Differences ............................... 57

Brief Statement ................................................ 58
Future Research ................................................ 58
Aﬁ‘ect Inventory .......................................... 58

viii

Statistical Power and Eﬂ'ect Size ............................. 59

Vignettes ............................................... 59

Diﬂ’erent Subjects ......................................... 61

Clinical Implications ............................................. 62
Conclusions ................................................... 64
APPENDD( A: Informed Consent ....................................... 66
APPENDIX B: Subject Demographics . ................................... 69
APPENDDI C: Sexual Orientation Data ................................... 71
APPENDD( D: Current Health Status .................................... 73
APPENDIX E: Intemalized Shame Scale .................................. 75
APPENDD( F: Vignette ............................................... 78
APPENDIX G: Vignette ............................................... 79
APPENDIX H: Vignette ............................................... 80
APPENDD( I: Vignette ............................................... 81
APPENDIX J: Intemalized Shame Scale .................................. 82
APPENDDI K: Aﬁ‘ect Inventory ........................................ 85
APPENDIX L: Brief Statement ......................................... 87
APPENDIX M: Frequency Data ......................................... 88
REFERENCES ....................... . .............................. 104

 

 

Table l

 

Table 2

Table 3

Table 4

Table 5

 

Table 1:

Table 2:

Table 3:

Table 4:

Table 5:

LIST OF TABLES

Mean scores for Intemalized Shame Scale-Self ratings and Projected
ratings and the Amount of Change between scores ..................... 98

Aﬁ‘ect Inventory Sub-scale, Adjectives, Corrected Item-Total Correlations,
and Sub-scale Alpha scores. .................................... 99

Correlation Matrix for eight Affect Inventory Sub-Scale headings. ....... 10]

Component Matrix of factor loadings on the two factor solution
revealed by Exploratory Factor Analysis of the Affect Inventory. ........ 102

Mean scores and Standard Deviations on the Negative-Aﬂ‘ect Factor of the
Affect Inventory .............................................. 103

CHAPTER 1
STATEMENT OF THE PROBLEM
In 1979, the signs of a disturbing medical phenomenon were ﬁrst identiﬁed in
medical settings in the United States (Curran, 1983).

An unidentiﬁed disease mysteriously focuses on one group. This group, of which
you are a member, is a minority.

Your friends are becoming ill and dying ugly and painful deaths. Even the ringing

of the telephone is no longer a ﬁiendly sound: it may bring yet more painﬁrl news.

You watch yourself daily for symptoms. People in the general population are

becoming ﬁightened of catching the disease from you. The government shows

curious lethargy in response to what has, in two years, become one of medical
history’s most enigmatic major epidemics. There is talk of quarantine.

The disease has an incubation period that can be as long as three years, and large

numbers of your group may already have contracted the dreaded disease without

knowing it. Even the most healthy-looking people may be capable of transmitting

the mysterious agent. Everyone is terriﬁed. (Morin, Charles, & Maylon, 1984)
Batchelor (1984, p. 1279) argued early on that “the mention of AIDS causes people to
draw back in fear; it has the emotional impact of a modem-day plague. AIDS has become
a psychological emergency” leading Odets to conclude that although “widely perceived as
an important medical issue, the AIDS epidemic is also a mental health catastrophe perhaps
unmatched in 20th century American history” (1995, p. 1).

By 1981, the ﬁrst deaths associated with that phenomenon - now known as two
separate but usually co-morbid diseases, Human Immunodeﬁciency Virus (HIV) and
Acquired Immune Deﬁciency Syndrome (AIDS) were identiﬁed and publicly reported by
the Centers for Disease Control and Prevention (CDC) (Batchelor, 1984; Nicholas, 1983).

While research into the physical and medical aspects of these diseases became popular,

there had been much less research on the psychological impact of HIV and AIDS.

In part, the need for further evaluation of the psychological ramiﬁcations of an
I-IIV-positive/AIDS diagnosis is evident from the fact that research conducted in this area
has yielded conﬂicting results. Some reports suggest that the impact of an HIV-positive
(HIV +) diagnosis involves tremendous stress and turmoil that can lead to signiﬁcant
psychological problems. Other studies, however, found statistically non-signiﬁcant results
emerge ﬁ'om comparing psychological proﬁles of people who are HIV+, and HIV-
negative (HIV -). Still other researchers have reported that, while important psychological
issues do arise, the progression of the illness accounts for most of the timing and severity
of those issues. Since the progression of HIV/AIDS does not follow any single consistent
path, one is left unsure about how and when to prepare for the associated psychological
difﬁculties. Effective coping requires an understanding of the psychological issues that a
person with AIDS will likely confront. These include, but are not limited to, reactions
engendered by societal attitudes toward people with AIDS along with the related feelings
of shame that are hypothesized to accompany an HIV+ diagnosis.

The shame about HIV and AIDS parallels the shame associated with
homosexuality. Kauﬁnan’s (1996) theory of shame and culture argues that all cultures
have their particular targets of shame. In American culture, sexual acts between
individuals of the same sex have become a primary target of shame. Homosexual
behaviors have been labeled as dirty, unnatural, against G-d’s intentions, inferior, etc.
Likewise, society has deemed people who engage in such acts as dirty, unnatural, inferior,
and as people who will suffer G-d’s wrath because they have gone against His will.
Furthermore, homosexual behavior has been so strongly shamed that homosexuals have

been viewed as not being human at all, leading some people to physically harm and kill

them.

Society’s message about homosexuality inﬂuences both society’s collective self-
concept, deﬁning its character, and the self-concept of the individuals who make up that
society. To the individual who experiences desire for same-sex affection, these messages
are personally shaming and the script that develops for that individual often becomes one
which is shame-based; the homosexual explains his own feelings and thus himselfas
ﬁrndarnentally bad, inferior, dirty, unnatural, etc.

The present study aimed to investigate the relationship between societal
stigrnatization, shame and HIV/AIDS, and also the relationship between stigrnatization,
shame, and homosexuality. Tomkins’s (1962, 1963, 1991, 1992) Affect Theory and
Kaufrnan’s Shame Theory (1992, 1996) served as the theoretical foundations for this
study. The current literature reports inconsistent results regarding the amount of
psychological distress found in HIV+ individuals compared to HIV- individuals. While
HIV+ status does likely result in increased levels of psychological disturbance, which is
often reported to include such global diagnoses as depression, anxiety, or adjustment
disorder (Brauer, 1994; Morin & Batchelor, 1984; Morin, Charles, & Maylon, 1984), this
connection is likely to be mediated by various processes. One such process is
hypothesized to be shame. This study aims to clarify the stigrnatization process along with
the role of shame in both HIV illness and homosexuality by examining how a normal
healthy population projects its own aﬂ‘ective reactions onto ﬁctitious people. Utilizing a
“projective” measure of shame will hopefully reveal the affective reactions generated by

HIV/AIDS and also by homosexuality.

 

 

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Substantial research already shows that a variety of people in completely diﬂ’erent
circumstances can share a common disdain for people who are either HIV+ or
homosexual. St. Lawrence, Husfeldt, Kelly, Hood, and Smith (1990) found that college
students had highly negative and almost interchangeable prejudices toward peOple with
AIDS and gay men. Other research teams have reported that people with negative
attitudes toward homosexual men also Show higher levels of stigrnatization toward People
with AIDS (Lennon & McDevitt, 1987 cited in St. Lawrence et al., 1990; O’Donnell et
al., 1987). Similarly, physicians, medical students, and nurses, in locations with low
numbers of People with AIDS, comparing two patients with the same descriptions except
for type of illness, have been found to rate people with AIDS as less deserving of medical
treatment, more responsible for their illness, less of a loss to the world if they died
compared to other patients, and more deserving of quarantine than others (Crandall, 1991;
Katz, Hass, Parisi, Astone, Wackenhut, & Gray, 1987; Kelly, St. Lawrence, Hood, Smith,
& Cook, 1987a; Kelly, St. Lawrence, Hood, Smith, & Cook, 1987b; Kelly, St. Lawrence,
Smith, Hood, & Cook, 1988; St. Lawrence, Kelly, Owen, Anthony, Indira, 1990). These
data suggest that even people who are presumed to be well educated regarding HIV/AIDS
are still prone to unfounded prejudice. Fortunately, because the people in this data sample
had little contact with HIV+/AIDS patients, they may not have had the opportunity to
directly impart to patients their prejudicial views. Such good fortune, however, will likely
not last since it is becoming clearer that the AIDS epidemic is no longer a problem limited

to large metropolitan epicenters. AS the epidemic continues to spread out ﬁ'om cities to

 

 

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smaller rural towns in the United States, there will be an increased need for psychologists
[and others] to be able to help people with AIDS. However, when St. Lawrence et al.,
(1990) examined the attitudes of 126 psychologists toward AIDS, the researchers found
that AIDS patients were perceived more negatively than others, and that participating
psychologists reported less willingness to interact with the AIDS patients either in a
professional role or in a casual social situation. In their research design, each participant
was asked to read one of four vignettes, which were identical in all respects except that
the subjects portrayed in the different vignettes were either homosexual or heterosexual,
and had either AIDS or Leukemia. Participating psychologists rated the vignette subjects
on three measures. First, the Prejudicial Evaluation Scale, a 12-item scale constructed to
assess health providers’ attitudes toward AIDS (Kelly, St. Lawrence, Hood, & Cook,
1987a). In this study, respondents rated each item on a 7-point Likert scale (e. g., ratings
from 1 = disagree to 7 = agree). Second, the Social Interaction Scale (SIS) includes
descriptions of seven casual social interactions that could take place with the person
described in the vignette. These were used to examine the subject’s willingness to interact
with the portrayed patient. An additional item evaluated the subject’s willingness to treat
the portrayed person in his/her clinical practice. Like the Prejudicial Evaluation Scale,
these items were also ranked on a 7-point Likert scale ranging ﬁ'om one to seven. The
third measure used in this study was the Interpersonal Evaluation Inventory (IE1). The
IE1 is an assessment tool sensitive to social evaluation and likeability. The [BI is made up
of 24 adjectives (e. g., warm, appropriate, truthful, kind, etc.) each of which is rated on a
7-point Likert scale (e.g., 1 = extremely open-minded to 7 = extremely close-minded) with

scoring direction counterbalanced to control for response set bias.

 

 

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As previously stated, St. Lawrence, et al., (1990) found that AIDS patients were
perceived more negatively than others, and that participating psychologists reported less
willingness to interact with the AIDS patients either in a professional role or in a casual
social situation. Interestingly, no signiﬁcant diﬁ‘erences were found between homosexual
and heterosexual variables.

As St. Lawrence, et al., (1990) report, the psychologists’ responses reveal their
underlying attitudes and also demonstrate similarities between psychologists in the sample
and the lay public:

Psychologists rated the AIDS patient as more responsible for his illness,

experiencing more pain and suffering, more dangerous to others, deserving of

the best medical care possible, a person for whom suicide is more likely to be

the best solution, and who is more deserving of quarantine. (1990, p. 360)

These data suggest that irrational fears may prevent psychologists from helping people
who may desire and require services, an unfortunate outcome for the profession of clinical
psychology. In fact, People with AIDS who receive services ﬁ'om a psychologist are
prone to have a negative experience due to the therapists’ biases, an experience also
reported by many homosexual men (Baron, 1996; Cornett, 1993; Fassinger, 1991; Martin,
1982; Morin & Rothblum, 1991). Conceivably, if the negative therapy encounter left the
client unwilling to attempt another therapy experience, and prevalence of therapy for
AIDS patients’ depends on reported therapy contacts, then this could account for the
reported decrease in psychopathology found among People with AIDS (Atkinson et al.,

1988)

Re chonI-IIV/AIDS de ' :TheRl f i

Psychological issues vitally important to our understanding and treatment of
People with HIV/AIDS have remained under represented in recent research efforts. This
is striking since having an awareness of psychological issues has been recognized by
experts as fundamental to our complete understanding of HIV /AIDS. To some
researchers the severe psychological impact of HIV /AIDS appears obvious (Brauer, 1994;
Morin & Batchelor, 1984; Morin, Charles & Maylon, 1984), while others report ﬁndings
which suggest less severe psychological problems. Although it is easy to see how
psychological distress embedded in one’s response to societal reactions to HIV/AIDS
would reasonably be expected to impact people who are aﬂlicted with HIV/AIDS, the
remaining confusion may be partly due to the lack of understanding about not only the
experiences of people who are either HIV+ or homosexual, but also the experience of
people who stigrnatize these groups. Therefore, attention must be given to understanding
the process of stigrnatization itself.

In recent years, researchers have begun to consider the impact of stigrnatization
(Baron, 1996; Chesney & F olkman, 1994; Herek & Glunt, 1988; Le Poire, Hiroshi, &
Hajek, (1997). However, the pioneering work by Irving Goffrnan (1963) is still
considered the cornerstone of understanding stigrnatization. Gomnan was the ﬁrst
researcher to describe the process of stigrnatization and his conceptualization of that
process, originally presented in Stigma: Notes on the Mmement 9f Spoiled Identity
(1963), has remained the primary treatise on this subject for more than 30 years.

Goﬂ’man deﬁnes stigma as an attribute or blemish of either physical characteristics

(e. g., a handicap, deformity), of character (e.g., mental disorder, untrustworthy), or of

tribal association (e. g., race, religion). He further deﬁnes the process of- stigrnatization as
taking place when one’s expectations of a person or group are changed by an awareness
of an “attribute or blemish” that is deemed abnormal and unexpected. This awareness
creates a conﬂict between the previous assumption of “normalcy” about the person or
group and the sudden awareness of an intrusion of the “abnormal.” When that occurs the
person with a blemish indeed has become stigmatized, excluded from the group called
“normals.”

Using Goﬂinan’s conceptualization, people who are HIV+ could be placed into the
stigmatized categories of physical handicaps due to illness and also of character due to
mental disorder (e. g., dementia). Likewise, homosexuals could be placed into the
stigmatized categories of having either a character blemish or one of tribal association.

There are many instances found in everyday life which would support Goffman’s
formulation. Examples of stigrnatization and discrimination suﬂ‘ered by People with AIDS
are well known to the general public through a bevy of popular articles reporting on the
traumatizing experiences and psychological stressors faced by them. Ship wrote that “a
Massachusetts teacher was ordered to take a medical leave and then to resign when
rumors circulated that he was being treated for AIDS. After demonstrating to school
oﬂicials that his medical problems were associated with a blood disorder not related to
AIDS, he was allowed to return to teaching. Threatening phone calls and harassment
continued, however, and he felt compelled to take a leave of absence” (The New York
Times, 1986, p. 8). William F. Buckley Jr. argued in 1986 that “everyone detected with
AIDS should be tattooed in the upper forearm, to protect common-needle users, and on

the buttocks, to prevent the victimization of other homosexuals” (The New York Times

 

 

 

 

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p. A 27), an approach reminiscent of Nazi Germany. And Robinson (1987), writing for
the Beach Globe, reported that in “Arcadia, Florida, three brothers tested positive for
Human Immunodeﬁciency Virus (HIV). After word spread of their infection, their barber
refused to cut the boys’ hair, and the family’s minister suggested they stay away from
Sunday church services. Eventually, the family’s house was burned down” (p. 1).

In these examples, society identiﬁed these individuals as belonging to a diﬂ‘erent
category than normal. Society also treated them differently than they would treat
someone considered “normal.” That is the process of stigrnatization.

Moreover, the events characterized above were traumatic. It would be diﬁcult for
anyone to suggest that such encounters, experienced either personally or vicariously via
identiﬁcation, would not have a powerful adverse impact on psychological health. Based
on the accumulated evidence, some researchers believe that increased levels of affective
disorders, adjustment disorders, stress, and even suicide have now been widely observed
among people diagnosed as HIV+ or having AIDS.

Persons with HIV/AIDS are also likely to be stigmatized on other grounds beyond
those directly related to HIV /AIDS. This additional stigma has been directed at
homosexuals and intravenous drug users (IVDU) and predates HIV/AIDS (Brauer, 1994;
Bennet, 1987; Crandall, Glor, & Britt, 1997; DeMarco, 1998; Herek & Glunt, 1988,
1991; Kauﬁnan, 1996; Kauﬁnan & Raphael, 1996; Limandri, 1989; Morin, Charles,
Maylon, 1984; Morin & Rothblum; 1991). Homosexuals and IVDU have long been
considered deviant and have been categorized as separate and diﬂ‘erent by people who
have been too uncomfortable to tolerate these diﬂ‘erences. Chronic grief/loss issues and

fear of public disclosure about sexual orientation and/or drug use are also concerns

 

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experienced by People with AIDS and would also be expected to impact both their lives
and daily activities (Altman, 1986; Bennet, 1987 ; Crandall & Coleman, 1991; Elford,
1987). Herek and Glunt (1988) reported that comprehending the “AIDS Epidemic in the
United States requires an understanding of the phenomenon of widespread, intensely
negative reactions to HIV-infected persons. These negative reactions have shaped the
behavior of infected individuals and have limited the effectiveness of prevention efforts”
(p. 886).

In addition to fear about the reactions ﬁom the general public, there is reason for
these people to fear reactions from those who should be in a position to help them. Aiter
all, members of the mental health profession have participated in the stigrnatization
process. In the case of stigrnatizing homosexuality, it is important to note that until 1973,
homosexuality was listed in the Diagnostic and Statigigaj Mmﬂ, Third Edition Reviﬂ
as a mental illness (Morin & Rothblum, 1991), placing homosexuality in the “blemish of
character” category described by Goffman. This classiﬁcation has allowed the mental
health profession to View homosexuals as separate and diﬂ‘erent from “normal people,”
establishing an “us and them” approach to diagnosis and therapy. The mental health
profession’s stigrnatizing practices have often created iatrogenic wounds while
simultaneously denying these populations the basic services available to others.

There are other psychological difﬁculties speciﬁc to HIV/AIDS, which therefore
have a selective impact on homosexuals and IVDU, namely grief and loss issues and the

effects of stress on the immune system.

10

Grief and Loss Issues

Grief and loss are generally experienced whenever people die, and death is
certainly a primary issue for people who are aﬂlicted with HIV/AIDS. The HIV + person
must deal not only with issues related to his/her own mortality, but with the loss of many
ﬁiends and loved ones as well. Tremendous numbers of losses are common in areas with
large numbers of People with HIV/AIDS. For example, considering New York and
California, these two locations combined to account for 56% of the national total number
of AIDS cases in the United States in 1986. Assuming that the death rate in both New
York and California was similar to the death rate in Michigan, then between 1981 and
1986 approximately 5020 people died of AIDS within six years of diagnosis (Michigan
Department of Public Health Acquired Immune Deﬁciency Syndrome Statistics, 1986).
This represents large numbers of people who have grieved the losses of loved ones, many
of whom were likely to have been HIV+ or AIDS infected themselves.

Equally as devastating can be grief over losses that are not speciﬁcally death-
related: loss of job due to poor health, loss of income, loss of lifestyle and socioeconomic
status, loss of family and ﬁiends who now discriminate, loss of religious support, loss of
physical/bodily control, loss of physical appearance do to illness, loss of freedom to travel
(either by government sanctions against people with HIV+/AIDS leaving and entering the
country or due to the necessity to be close to one’s doctor and pharmacist), and loss of
sexual contact due to fear of contaminating another (Lopez & Getzel, 1984; Morin,
Charles, Maylon, 1984; O’Rourke & Sutherland, 1994; Ruhala & Woodring, 1993). This
list only scratches the surface of the many losses suffered by HIV/AIDS infected peOple.

Such losses would undoubtedly be characterized as stressﬁrl and problematic in anyone’s

ll

life. However, because they are multiple and cumulative, the effects of stress are more
signiﬁcant to the person who is HIV+/AIDS than to other people.

Psychoirnmunology. The many losses experienced by persons at risk for infection
by HIV put additional stress directly on the immune system. Psychoirnmunology is the
study of the immune system’s reactions to stress and other signiﬁcant life events. The
evidence now clearly demonstrates that psychological issues such as distress, bereavement,
disruption in personal relationships, and transitional life events have a signiﬁcant effect on
the immune system (Bloom, Asher, & White, 1978; Cohen & Syme, 1985; Kiecolt-Glaser
& Glaser, 1988; Renne, 1971; Verbrugge, 1979). The biological process implicated here,
though complex, has been documented.

There are multiple biological processes which combine to inﬂuence the immune
system, suggesting that one area of immune system functioning affects other areas of
immune system function. For example, the endocrine system, which has been shown to be
responsive to different emotional states and levels of stress (Baum, Grunberg, Singer,
1982), has also been found to have considerable effect on the number of t-cells (a central
component of the immune system) in the blood. Epidemiological studies have found
support for the idea that emotional states and interpersonal relationships have health-
related consequences: changes in emotional states and levels of stress have a weakening
effect on immune system functioning. For example, Cohen and Syrne (1985) found
greater morbidity and mortality in people who have fewer close relationships. Bloom,
Asher, and White (1971) showed that both the quality of relationships and disruption of
relationships are important determinants of physical health. Likewise, studies looking at

physical health following marital separation and/or divorce have shown higher rates of

12

infectious disease and cancer (Emster, Sacks, Selvin, & Petrakis, 1979; Somers, 1979)
following disconnection from one’s spouse. Similarly, data from bereavement studies
show that men who have wives dying of breast cancer also have poorer lymphocyte
proliferation (development of immune system blood cells) following their spouse’s death
than before (Schleifer, Keller, Camerino, Thornton, & Stein, 1983). Also, in recently
bereaved women, there is lower natural killer cell activity (immune system blood cells)
than in age-matched non-bereaved women (Irwin, Daniels, Smith, Bloom, & Weiner,
1987)

These ﬁndings are particularly important for People with HIV/AIDS. Those
communities which have been most aﬂ‘ected by AIDS, such as the homosexual and IVDU
communities, have encountered large numbers of losses and have grieved the deaths of
countless people who have fallen to AIDS. These same communities have experienced
signiﬁcant amounts of stress due to stigrnatization, discrimination, and poor health. It
must be recognized that many of the people living in these communities who are grieving
losses are also HIV+/AIDS patients. In fact, in many instances entire families are
HIV+/AIDS patients. This results from the sexual transmission of the virus and
subsequent transmission ﬁ'om mother to an unborn fetus (Sherr, 1995).

Finally, repeated stress or grieving does not appear to be something that the body
and immune system readily adjust to. This has been shown in a series of studies by Glaser,
Rice, Speicher, Stout, and Kiecolt-Glaser (1986) using medical students as subjects.
Blood samples one month prior to medical school exams (low stress period) were
compared to blood samples taken during examinations (high stress period). The results

showed that blood samples taken during periods of high stress had lower levels of immune

13

system cellular activity (i.e., the presence of natural killer cells) compared to low stress
periods. This suggested poor immune system functioning during stressful times.
Moreover, in spite of these students’ long history of successful exam-taking behavior,
which is implied by having achieved medical school entrance status, repeated instances of
stress do not appear to help one’s body react more eﬁciently to ﬁrture stress.

In summary, grieving for friends and loved ones who have died of AIDS, along
with other life stressors including those associated with stigrnatization, all contribute to a
general weakening of the immune system. For HIV+/AIDS patients, these stressﬁrl events
negatively impact an already compromised immune system. This data alone highlights the
need to more effectively conﬁ'ont the psychological issues encountered by the HIV+/AIDS

communities.

14

Studies of HIV/AIDS and Psychological Digrdersz
Methodological Problems grd Conﬂicting Findings Sigma

the Need for New Re ch P i

One source of information regarding the psychological impact of AIDS is research
evaluating the connection between HIV/AIDS and depression/anxiety, suicidal behavior,
and adjustment disorders. While certain research reports reveal statistically signiﬁcant
diﬁerences in psychological health between HIV + and HIV- people, other studies report
no signiﬁcant diﬂ‘erences.
Sigm' gant Remch Findings

Researchers studying the psychological dimensions of HIV /AIDS have commonly
used subjects from high-risk groups, primarily consisting of intravenous drug users
(Hestad, Aukrust, Ellersten, & Klove, 1994; Lipsitz, et al., 1994; Pakesch et al., 1992) and
men who have sex with men either exclusively or in addition to women (Atkinson, Grant,
Kennedy, Richman, Spector, & McCutchan, 1988; Bungener, et al., 1993; Catalan et al.,
1992; Chuang, Jason, Pajurkova, & Gill, 1992; Ostrow et al., 1989), so that the
psychological ramiﬁcations of being a drug user or homosexual are confounded with those
speciﬁcally related to AIDS. Within these groups, researchers have focused on three main
areas of psychological disturbance: 1) affective disorders including depression and anxiety
(Atkinson, Grant, Kennedy, Richman, Spector, & McCutchan, 1988; Cazzullo, Folkman,
Chesney, Pollack, & Coates, 1993; Ostrow, Joseph, Kessler, Soucy, Tal, Eller, Chmiel, &
Phair, 1983; Ostrow, Monjan, Joseph, VanRaden, Fox, Kingsley, Dudley, & Phair, 1989);
2) adjustment disorders (Bungener, Kosmadakis, Jouvent, & Widlocher, 1993; Lipsitz,

Williams, Rabkin, Remien, Bradbury, Sadr, Goetz, Sorrel], & German, 1994); and 3) rates

15

of suicide (Gala, Pergami, Catalan, & Riccio, 1992; McKegney & O’Dowd, 1992; Rajs &
Fugelstad, 1992).

In an early report, Atkinson, et al., (1988) studied depression and anxiety in ﬁve
subject groups: 1) homosexual men given an AIDS diagnosis using the CDC criteria; 2)
homosexual men given a diagnosis of AIDS Related Complex (ARC) using the CDC/NIH
criteria; 3) homosexual men diagnosed HIV+ but not diagnosed with AIDS or ARC; 4)
homosexual men who were HIV-; and 5) heterosexual men who were considered healthy.
These researchers investigated the prevalence of psychiatric/psychological disorders in gay
male subjects with AIDS in order to evaluate whether the common reports of increased
rates of depression and anxiety were a product of a subject selection artifact. In
addressing this question, the research team investigated psychological problems in terms
of lifetime prevalence, six-month prevalence, and the onset of problems in relation to a
diagnosis of AIDS or ARC. The psychological status of gay men who were HIV+ was
also compared to that of gay men who were HIV- and to heterosexual men who were
healthy. All groups were evaluated for the pre-morbid prevalence of psychiatric illness.

Their results indicated that the groups of homosexual men had a high rate of
lifetime prevalence of diagnosable psychological illness. Although the majority of the
homosexual men developed diagnosable disorders of one type or another prior to
becoming HIV+ or acquiring AIDS or ARC diagnoses, “only 4 of 17 (23.5%) noted the
onset of generalized anxiety disorder at a time remote ﬁ'om the beginning of the AIDS
epidemic” (Atkinson et al., 1988, p. 863). Additionally, the AIDS population in this study
demonstrated higher rates of major depression for both lifetime (30.3%) and past-six

month periods (10.7%) compared to the results of pooled data from the epidemiologic

l6

catchment area reporting lifetime and current estimates of 5%, and 3%, respectively, for
similarly aged men. The AIDS population in this study also surpassed the control group’s
rates of 10% and 0%, respectively, on these dimensions. Even though the results were not
statistically signiﬁcant, these researchers have observed an important psychological
phenomenon.

What was found to be statistically signiﬁcant were those differences between the
HIV+ group of gay men compared to the control group of heterosexual HIV - men.
Comparing the lifetime prevalence of psychiatric disorders, 88.2% of the gay HIV+ men
had a diagnostic history of psychological disturbance compared to 59.1% of the
heterosexual HIV - control group. However, that diagnostic history always predated the
HIV+ diagnosis. While it is impossible to conclude that the psychopathology observed in
this sample resulted from an HIV+ diagnosis (Atkinson et al., 1988), it may still have
increased vulnerability to future episodes of diagnosable psychological problems, due to
AIDS.

In another investigation of the psychological concornitants of AIDS, Johannet and
Muskin (1990) gathered data from inpatient hospital charts and found that People with
AIDS had higher rates of psychiatric consultations than any other group of inpatients.
Similarly, O’Dowd and McKegney (1990) found that HIV + patients and People with
AIDS had more repeated contacts with the psychiatric staﬂ‘ compared to other inpatient
groups. Finally, Sacks et al., (1995) reported that a small but a signiﬁcant increase in the
number of new psychiatric inpatients who may not have otherwise entered inpatient
treatment appears to have been brought about by the AIDS epidemic.

The data presented above lead to the conclusion that a diagnosis of HIV or AIDS

17

creates such a high level of psychological distress that it drives people to seek professional
assistance. These data must be interpreted cautiously, however, for two reasons. First,
these subjects comprised a specialized group because they were all inpatients; thus, the
results do not necessarily generalize to people who do not require inpatient psychiatric
treatment. Second, people who are on an inpatient unit may already have a more serious
condition than those who are not hospitalized. Conversely, if the more physically
compromised person does choose to seek psychiatric consultation because of increased
distress and pain, being at a more difﬁcult time in life or being closer to death, then such
action could instead be viewed as a Sign of positive mental health in the form of disease
acceptance and eﬂ‘orts toward self-empowerment, not psychological pathology.

In other research, O’Dowd, Natali, Orr, and McKegney (1991) reported on data
gathered from charts of patients at an outpatient HIV psychiatric clinic which is aﬁliated
with a large hospital in New York City. The hospital was responsible for 82% of the
referrals while the remaining 18% of referrals came from outside sources. The questions
being examined were: 1) Why did 50% of the referrals never attend their ﬁrst
appointment? 2) Why did 45% of the patients not return following a ﬁrst appointment?
3) Were there demographic characteristics of the referred population which could be used
to predict appointment keeping/appointment breaking behavior? Demographic variables
taken from hospital charts were examined to evaluate possible diﬂ‘erences between 100
patients who never attended their ﬁrst appointment and 224 patients who completed the
entire intake process (N = 324).

The results showed that of the 324 cases at least one Axis I diagnosis from DSM-

III-R was given to 98% of the peOple; 44% had previous psychiatric treatment; 31% had a

18

history of psychiatric hospitalization; and 38% had a history of outpatient treatment. The
most common diagnosis given at the time these hospital charts were created was
adjustment disorder (65%), followed by substance abuse (44%), while only 12% were
diagnosed with an aﬂ’ective disorder. The small percentage of affective disorders was
unexpected, leading the authors to conclude that this ﬁnding may have been the
consequence of under-reporting since they did not distinguish between subtypes of
adjustment disorders, but instead found many individuals diagnosed with an adjustment
disorder to also be depressed and anxious. The possibility remains that the subjects did
not feel the need for mental health treatment, but the health professional making the
referral determined that a referral was necessary.

Still, another factor may help explain the ﬁndings with regard to affective
disorders. It is important to note that the current DSM-IV criteria for diagnosing aﬂ‘ective
disorders employs qualifying statements regarding substance abuse as an etiologic
component of the aﬂ‘ective disorder. Therefore, in the O’Dowd et al., (1991) study,
elevated levels of substance abuse may well have limited accuracy when diagnosing
affective disorders.

Conversely, O’Dowd et al., (1991) also found that patients who had a history of
substance abuse and were currently involved in a methadone program were more likely to
remain in the program compared to those who were not on methadone. Those people
who received prescription medication at their ﬁrst visit were also more like to stay
connected to the program than those who did not receive a prescription. Finally, although
not a signiﬁcant difference, those people who were receiving AZT medication were more

likely to continue with treatment than those who did not receive AZT medication. The

19

authors speculated that those “individuals who have been able to organize themselves
suﬂiciently to use other programs — whether psychiatric clinics, methadone programs, or
AZT clinics — are perhaps more likely to be able to continue in a new program” (O’Dowd,
Natali, Orr, & McKegney, 1991, p. 618).

O’Dowd et al., (1991) gathered useful information in their attempt to understand
the characteristics of the people served in their mental health clinic, especially given the
unique presenting problem of these people. This study suggests that many people who
have AIDS are seen by the medical community as needing psychiatric attention. It would
have been more useful, however, to have comparison data for the general population’s
rate of “no-show and early dropout” behaviors for psychiatric appointments. The
possibility exists that the number of people who do not show for an initial psychiatric
appointment, or do not return for second psychiatric appointments are the same as in the
data presented by O’Dowd et al., (1991), regardless of the population being served.

In another study (Lipsitz, Williams, Rabkin, & Remien, 1994), HIV + and I-IIV-,
male and female intravenous drug users were subjects for an evaluation of their levels of
psychopathology. Using the Structured Clinical Interview along with measures of
symptom severity, global functioning, and stress, the results obtained showed that the
prevalence of a current diagnosis of depression and symptom severity for both depression
and anxiety were higher among these subject groups than within the wider community.
Although much of the depression was accounted for by the history of drug abuse, sub-
sarnples of this population revealed depression which was strongly linked to HIV
infection. For instance, relative to other drug users, HIV+ men demonstrated a higher

prevalence of depressive disorder than I-IIV- men. The severity of both depressive and

20

anxiety symptoms were also related to the symptom-based measure of HIV (Lipsitz,
Williams, Rabkin, & Remien, 1994).

In a ﬁve-year longitudinal study, Rosenberger et al., (1993) found that an HIV+
diagnosis does not precede, but can nevertheless contribute to, the acute presentation of
psychiatric illness. The data suggest that a positive diagnosis of HIV infection did not
cause psychiatric disorders in this sample, a ﬁnding consistent with other research.
However, the stressful events which stem from HIV-related problems can serve as a
catalyst for new episodes of anxiety, substance abuse, and adjustment difﬁculties.

More speciﬁcally, Rosenberger et al., (1993) studied 197 gay and bisexual men
who were either HIV+ and asymptomatic since diagnosis (N = 102), HIV+ with
symptoms (N = 64), or HIV- (N = 31). They were given psychological evaluations to
determine both their current and lifetime psychiatric functioning. As in other studies
considering lifetime prevalence of psychiatric disorders (e.g., Atkinson, et al., 1988;
Williams, Rabkin, Remien, Gorman, Ehrhardt, 1991), Rosenberger et al., (1993) found
elevated rates of the lifetime psychiatric disorders in 166 HIV+ subjects. There were no
signiﬁcant differences between asymptomatic and symptomatic groups. When the two
HIV+ groups were pooled, 79% of those subjects diagnosed with Affective Disorders
reported their ﬁrst episode prior to diagnosis of HIV infection. More speciﬁcally, 73% of
the sample with a history of Major Depression reported their ﬁrst episode prior to their
HIV diagnosis, while 98% of those subjects diagnosed with a history of substance abuse
reported an initial depressive episode prior to their HIV diagnosis.

Less dramatic ﬁndings suggested that 38% of the subjects with a history of

Anxiety Disorder and 33% with a history of Adjustment Disorder reported their ﬁrst

21

episodes prior to their HIV+ diagnosis. However, 12% of the HIV-infected subjects with
a history of Anxiety Disorder reported at least one episode precipitated by HIV-related
events, often positive diagnosis of HIV status on initial hospitalization for HIV illness.
One percent of subjects with a history of Substance Abuse and 33% of subjects with a
history of Adjustment Disorder reported an episode of symptoms, but following HIV-
related events (Rosenberger et al., 1993).

In summary, some studies provide evidence that HIV/AIDS are highly correlated
with psychological problems which are signiﬁcant enough to require either a diagnosis or
professional attention (Atkins et al., 1998). Similarly, there is evidence suggesting that,
compared to others on inpatient units, those who have AIDS also have the most ﬁ'equent
requests for psychiatric consultations (J ohannet & Muskin, 1990; O’Dowd & McKegney,
1990). Finally, there are now studies which connect diagnoses of psychological disorders
and HIV status (O’Dowd et al., 1991). As stated earlier, many of these studies are
fraught with methodological problems which presumably have impacted their results. In
many instances, the research methods used and choice of research subjects introduced
confounding variables which contaminated the ﬁndings.

Non-Sigm'ﬂmt Research Findings

Many of the dimculties in interpreting the studies just reviewed involve sample
demand characteristics, especially risk group characteristics. For example, some
researchers with intravenous drug user samples have not yet found ways to understand the
impact of the diagnosis without including confounding variables associated with drug use.
These variables include illicit behavior (e. g., using illicit drugs, stealing, sexual exploitation

for drugs) and common beliefs that drug addicts are not trustworthy. Furthermore, this

22

subculture has diﬂiculty trusting the mainstream culture which raises questions about
diﬂ‘erences between those IVDU who cooperate with research programs compared to
those who do not cooperate (Rugg, Hovell, F ranzini, 1990). These confounding variables
make an accurate interpretation of collected data nearly impossible.

For high risk groups, such as homosexuals and IVDU, a history of psychiatric
disorders prior to HIV+ diagnosis also has been used to explain diagnoses subsequent to
HIV. This raises the question whether a subsequent diagnosis is the result of a person
receiving an HIV + status or the result of a natural progression of depression/anxiety,
adjustment disorder, and the like (Atkinson et al., 1988; Johannet & Muskin, 1990;
O’Dowd & McKegney, 1990; Rosenberger et al., 1993). The possibility exists that an
HIV+ diagnosis would be dealt with diﬂ‘erently by a person with a history of mental health
problems than by a person without such a history.

Another explanation for inconsistent ﬁndings regarding a connection between HIV
status and psychiatric illness is that non-signiﬁcant ﬁndings, especially those found in
studies of aﬁ‘ect disorders, stem from faulty hypotheses generated by researchers. As
Chesney and Folkman (1994) suggest, one reason for the continued focus on
depression/anxiety, suicide, and adjustment disorders, particularly given a decline in the
number of signiﬁcant results, is that during the early years of the HIV epidemic a positive
diagnosis of HIV infection was indeed associated with depression/anxiety, somatic
complaints, and suicidal ideation (Jacobsen, Peny, & Hirsch, 1990; Ostrwo, Joseph,
Kessler, 1989).

Chesney and F olkrnan further suggest that research which linked HIV+ status to

psychiatric problems in general did have validity at one time, but may no longer be valid.

23

These researchers argue that “the evidence of adverse psychological eﬂ‘ects of HIV
infection diminished after 1988 despite the growing numbers of infected individuals and
the spread of the epidemic outside the primary risk groups of gay and bisexual men,
injection drug users, and individuals ﬁ'om Haiti” (Chesney & Folkman, 1994, p. 164).
This research team attributes the diminishing signiﬁcant results (and thus diminished
negative psychological experience) to better pre- and post-test counseling along with an
increase in the number of effective treatments that can offer a higher quality of life. For
example, research results collected in 1985 revealed a high rate of suicide among people
diagnosed with AIDS (Kizer, Green, Perkins, et al., 1988; Marzuk, Tierney, Tardiﬂ', et al.,
1988), whereas by 1993, Rabkin, Remien, Katoﬂ‘ and Williams (1993), reported an
absence of suicidal ideation in gay men living with AIDS for at least three years.
Likewise, Schneider, Taylor, Hammen, et al., (1991) reported that a cohort of
asymptomatic HIV+ gay men had levels of suicidal ideation similar to that in an

HIV- comparison group.

Chesney and Folkrnan’s ( 1994) interpretations of the reports, suggesting a decline
in signiﬁcant amounts of psychiatric problems related to HIV status has merit, but also
raises additional questions. Considering Chesney and Folkman’s conclusion that negative
psychological effects of HIV infection decreased after 1988 in spite of the increasing
numbers of infected individuals and the new awareness of the virus in people outside the
primary risk groups of homosexual and bisexual men, IVDU, and individuals from Haiti”
(Chesney & Folkman, 1994, p. 164), why would one predict decreased psychopathology
instead of increased psychopathology? Chesney and Folkman’s supposition is in conﬂict

with theories that speak strongly to the stigrnatization which has followed groups that are

24

viewed as different, such as homosexuals and IVDU, and that have been attached to the
HIV+/AIDS populations as well. It would seem more likely to conclude that an

expanding population of people deemed “high-risk” should, in turn, increase the amount of
psychopathology, not diminish it.

In summary, the results of these studies taken together have been equivocal. Some
show psychological distress to be greater in people who are HIV+ compared to those who
are HIV - (Johannet & Muskin, 1990;Be1kin, Fleishman, Stein, Piette, & Mor, 1992;
Bungener, Kosmadakis, Jouvent, & Widlocher, 1993; Fleishman & Fogel, 1994; Hayes,
Turner, & Coates, 1992; Sacks, Burton, Dermatis, Looser-Ott, & Perry, 1995). Others,
however, suggest that differences are less obvious if in fact they even exist at all (Atkinson
et al., 1988; Lipsitz, Williams, Rabkin, & Remien, 1994; O’Dowd, Natali, Orr, &
McKegney, 1991; Rosenberger et al., 1993). These accumulating results have forced
researchers to reevaluate the accuracy of the heretofore “common sense assumption” that
an HIV or AIDS diagnosis produces psychological disruption.

One way to reconcile these inconsistent results is by realizing that researchers have
continued to expect the signs of mental health disturbance to take the particular form of
depression/anxiety, suicidal behavior, and/or adjustment disorders as deﬁned by the DSM
criteria. While there certainly may be memories of times ﬁlled with depression/anxiety,
suicidal ideation, and adjustment diﬂiculties, continuing to look for only these speciﬁc
problems is not the soundest research strategy. Such gross symptomotology as deﬁned by
the DSM may not, at the end of the 1990s, resonate as the primary issues for people who
are HIV+ or for People with AIDS.

An alternative approach to the study of psychopathology related to HIV infection

25

is likely to yield more deﬁnitive results. Instead of focusing on symptom patterns that may
or may not coalesce to form a depressive disorder, the present study aimed to articulate a
different paradigm. This paradigm focused on society’s affective reactions toward both
AIDS and homosexuals along with the impact of societal reactions directly on People with
AIDS and on homosexuals. It is precisely here that Goffman’s early work on the process
of stigrnatization reasserts itself. Studying society’s reactions to its outcasts means
studying stigma and how it arises in social groups. But Gofﬁnan’s thesis lacked one vital
component: awareness of m. He lacked both an understanding of affect and a
language for accurately partitioning affect. Any research on stigrnas must focus directly
on affect. The research paradigm utilized in this study is informed by Affect Theory and
Shame Theory, each of which is grounded in coherent psychological theory.

Affect Theory and Shame Theog:

Early Formulations Ed Later Theories of Shame

 

Shame has not received extensive attention in the psychological literature until
relatively recently. While Freud certainly touched on shame (Freud, 1930, 1933), more
attention was focused on guilt (Kauﬁnan, 1996) whereas Adler, in contrast to Freud, paid
much more attention to the effects of shame. The focus on inferiority feelings and the
concept of inferiority complex (1933) are examples of Adler’s increased awareness of the
signiﬁcance of shame-related phenomena (Kaufman, 1996). Conceptually, Adler’s
“inferiority complex” represents an early attempt to include shame as a key dynamic in the
development of personality. Nevertheless, although “Adler seemed to perceive the eﬂ‘ects
of shame, he lacked an affect theory and a sufﬁcient language to partition and rearrange

the perceived data” (Kaufman, 1996, p. 8).

26

In another example of early psychoanalytic perspectives on shame, Karen Homey’s
theory of safety and satisfaction is suggestive of the interpersonal bridge concept of
shame theory described by Kaufman (1996). In Homey’s theory of development, for
example, parents can undermine a child’s sense of safety and security by acting in a variety
of damaging ways. These include an obvious preference for one sibling over another,
unkept promises, ridicule, humiliation, and isolation of the child from others (Schultz,
1986). Although Homey does not Speak of shame per se, she describes situations and
feelings which have more recently been included under the rubric of shame. Thus, where
Homey employs examples of parental preference for another sibling, Kauﬁnan refers to
feeling inadequate or lesser; where Homey describes broken promises, Kaufman speciﬁes
disappointment and feeling unworthy of parental interest. Moreover, ridicule and
humiliation a la Homey result in feeling exposed or seen a la Kaufman; and forced
isolation readily implies stigrnatization. These are all examples of breaking the
interpersonal bridge, which Kauﬁnan characterizes as an activator of shame. In Homey’s
theory we see a description of, but not a direct reference to, shame as a central construct.
One reason for this is that, prior to Kauﬁnan’s work, there was no coherent vocabulary to
accurately label shame. Without such a language, shame could not be readily incorporated
as a primary factor in personality development.

Likewise, Erik Erikson (1950) argued that shame occupied an important place in
the stages of identity crises that span the life cycle. Erikson related shame speciﬁcally to
toilet training, the second stage of his life cycle schema, and the outcome of toilet training

is autonomy vs. shame and doubt. As Kaufman points out, however,

27

in Erikson’s conceptualization of each of these recurring crises, it seems evident

that each subsequent stage represents a linguistic transfonnation of shame. The

poles of each identity crisis include basic trust vs. basic mistrust, autonomy vs.
shame and doubt, initiative vs. guilt, industry vs. inferiority, identity vs. role
conﬁision, intimacy vs. isolation, generativity vs. stagnation, ego integrity vs.
despair. Those cognitive symbols reﬂect differences not in affect per se but in co-
assemblies of affect with perceived causes, targets, and consequences. (Kauﬁnan,

1996, p. 9-10)

More recently, a number of theories have emerged which elevate shame to the
status of a primary construct in personality development, with those developed by
Kaufman (1992, 1996) Kaufman and Raphael (1996), Lewis (1971), Nathanson (1994),
Tangney (1995), Wurmser (1981), and Morrison (1983) receiving considerable attention.
Each of these theories is somewhat diﬂ‘erent; and each speciﬁes a somewhat different
relationship between shame and other constructs such as guilt, pride, and embarrassment.
Yet, many of these theories have signiﬁcant psychoanalytic underpinnings.

Helen Block Lewis (1971, 1981, 1987a, 1987b), a psychoanalytic theorist,
considered the relationship between guilt, shame, identiﬁcation, and the superego. Guilt
and shame are viewed differently by Lewis, although they are considered equally advanced
superego functions which develop along diﬂ‘erent routes of identiﬁcation. Guilt is
generated by identiﬁcation with an aggressive parent, which then becomes an internalized
threat. Shame, in contrast, is generated by identiﬁcation with the admired ego-ideal,
which theoretically stirs feelings of triumph and pride, but leads to shame if one fails to
live up to expectations associated with this ideal.

Broucek (1982) and Morrison (1983) also conceptualized shame from a

psychoanalytic perspective. In contrast to Lewis’s emphases on ego-ideal processes,

Broucek considered shame in the context of already established psychoanalytic theory

28

regarding narcissism and anxiety, as well as narcissism and self-esteem. Additionally,
Morrison coupled shame and narcissism with Kohut’s Self-Psychology. Together, these
theorists helped to move shame to a more prominent position in the ﬁeld of psychology.
Their use of psychoanalytic concepts, however, has also impeded our ability to understand
shame in relation to other constructs (Kaufman, 1996). The language of psychoanalysis,
which is inherently rooted in drive theory, does not readily integrate the concept of aﬂ‘ect,
and therefore presents a barrier to theorizing about shame speciﬁcally as an aﬂ‘ect. Other
theories are available which are better able to describe shame and make the construct
useﬁrl ﬁ'om the vantage point of both theory and research.

Tomkins’s (1962) Affect Theory perspective on shame, which has been elaborated
by Kauﬁnan (1992, 1996) and incorporated into Kauﬁnan’s Shame Theory (Kaufman &
Bly, 1995; Kaufman & Raphael, 1991, 1996), provides the soundest means of directly
linking the construct of shame to current psychological theory and research.

Aﬂ‘ect Theog

Affect theory is the only theory that Offers both a model for understanding aﬂ’ect in
general and a language for differentiating among particular affects (Kauﬁnan, 1996). In
Tomkins’s theory, affect is primary over cognition or behavior:

I see affect or feeling as the primary innate biological motivating mechanism,

more urgent than drive deprivation and pleasure and more urgent than even

physical pain. Without its ampliﬁcation, nothing else matters, and with its

ampliﬁcation anything can matter (1987, p. 137)

Other investigations of positive and negative aﬂ’ectivity (Socall, 1995; Watson &
Tellegen, 1985; Zevon & Tellegen, 1982) have validated Tomkins’s (1962) theory,

suggesting two main rudimentary dimensions of moods. Positive affectivity is measured

by the extent to which a person feels enthusiastic, active, and alert. Conversely, negative

29

aﬂ‘ectivity is characterized by sadness and lethargy. Research (Watson, Clark, & Tellegen,
1988) shows that positive and negative affectivity represents two major human trait
dimensions, consistent with Tomkins’s aﬁ‘ect theory, but only one empirical study to date
(Socall, 1995) has examined the relationship between positive and negative aﬁ‘ectivity and
the constructs of shame and pride. Socall (1995) found a strong correlation between gay
identity-based pride and positive affectivity, as well as a strong correlation between gay
identity-based shame and negative aﬂ‘ectivity, suggesting that, consistent with affect
theory, shame and pride are components of positive and negative aﬁ‘ectivity, respectively.

The free and open expression of aﬂ‘ect is powerful and highly contagious
(Kaufman, 1996). For this reason, all societies have developed regulatory mechanisms in
order to govern its expression. For example, public displays of anger and distress (crying)
as well as expressions of physical affection between men are socially prohibited (Socall,
1995). Tomkins (1963) posited that shame occupies a unique place in this process
because it can be activated by any perceived obstruction to the ﬁee expression of the
positive affects. To be precise, Tomkins views shame as an auxiliary affect, which means
that any impediment that prevents a person ﬁ'om continuing to express positive aﬂ’ect will
innately activate shame. Furthermore, since stress is the result of affect suppression, the
socialization rules prohibiting the full expression of aﬂ‘ect, whether positive or negative,
contributes directly to both stress and further shame.

Tomkins (1987) argues that the affects are biologically based and stored in
programs located in the central nervous system, and that the face is the central site of
aﬂ‘ect generation and affect feedback. Tomkins pointed speciﬁcally to the skin of the face

as the main site for experiencing affect. It is the feedback from changes in facial muscles

30

that generate the “feeling” of speciﬁc affects. Tomkins ﬁrrther argues that the human
face’s ability to display complex aﬂ‘ective information derives from an evolutionary need
for a mechanism for generating feedback.

There is a clearly deﬁned set of facial behaviors which both signify and
communicate the aﬂ’ect of shame, initially to oneself and subsequently to others. These
include hanging the head, lowering or averting the eyes, and blushing (Kauﬁnan, 1996).
These facial signals communicate shame and also reduce the exposure associated with
shame by limiting visibility of the face.

In contrast to theories which suggest that visceral reactions are the primary
location for affective awareness, Tomkins views the outer skeletal and inner visceral
responses as the secondary sites for affect expression. Although the aﬂ‘ects are innate,
they can nevertheless be inﬂuenced and modiﬁed by environmental experience, especially
socialization, and can also become activated by learned triggers.

Aﬂ‘ect theory suggests that shame is initially activated whenever there is a partial
reduction in positive affect. This can happen, for example, when a person’s primary
assumptions about himself or herself are exposed as wrong. Thus, if a person believes she
is good at a task and then discovers she is not as good as she thought, shame becomes
activated. The identical process is observed when a closeted gay man, believing that he
ﬁnally has the conﬁdence to reveal his true self, suddenly cannot ﬁnd the courage to do
so - causing shame to be activated. In this instance, shame additionally acts as an

inhibitory mechanism to the further expression of positive affect.

31

Shame Theory
According to Kauﬁnan (1992, 1996), the principal way in which shame becomes

activated is interpersonally. Typically, shame originates in childhood and is linked directly
to the disruption of a child’s developmentally based, interpersonal needs. In order to
experience secure relationships, children must have their interpersonal needs adequately
responded to by care givers. When this does not occur, shame becomes activated. Ifthe
lack of responsiveness is only occasional, then shame need not be overwhelming when it
does occur, and the child can even develop a healthy awareness of limits as well as
increased tolerance for disappointment. However, if the interpersonal context of not
having one’s needs met becomes too ﬁequent, then the child will search for new meaning
in this experience. Since adults inevitably appear infallible and all-powerful to children, a
child may conclude, erroneously, that the disappointment and pain caused by these “failed”
interactions must be his/her own fault. Because the child blames himself or herself for
damaging the relationship, which Kauﬁnan calls breaking the “interpersonal bridge,”
shame is the inevitable result. Here, shame is activated by any experience that breaks the
interpersonal bridge linking the child to a parent or signiﬁcant other. Following such
ruptures, the child begins to develop feelings of not being worthy of love, which is
reinforced on each occasion that the child’s needs are again not met. Ultimately, these
feelings result in the internalization of shame - the child becomes convinced that there is
something fundamentally wrong with him, and therefore feels inferior.

In further examining the qualities and signiﬁcance of the interpersonal activators of
shame, consider the pre-verbal activators of shame (Kaufman, 1996). The ﬁrst occasion in

which a parent becomes angry with a child can itself activate shame, particularly in the

32

earliest years before language has developed. The anger of a parent is inevitably
experienced by a child as a rupture of the interpersonal bridge, which is the vital nurturing
required by every young child. When a newly verbal child experiences parental anger for
the ﬁrst time, that child may respond by saying, in eﬂ’ect, “you don’t like me anymore,”
signaling disruption of the interpersonal bridge. Furthermore, the affective experience of
shame is likely to make the child feel additionally powerless, and that powerlessness itself
will, in turn, activate additional feelings of shame. Repeated exposure to shame will result
in shame experiences becoming gradually more internalized.

The internalization process is conceptualized as the ability of the self to reproduce
its own experience, which allows the self to both ﬁrnction and develop further. The
process of internalization takes place directly through imagery (Kaufman, 1996). It is the
visual, auditory, and kinesthetic components of internal imagery which enable the self to
internalize any affective experience. Both the physiological drives, such as sex and
hunger, and the various interpersonal needs require ampliﬁcation by affect. The sex drive,
for example, requires fusion with excitement and enjoyment, both positive aﬂ‘ects, in order
for potency and integration to occur. The ﬁrst Sign of negative affect disrupts sexual
pleasure and inhibits the development of satisfying sexual relations.

What ultimately becomes internalized are distinct images that have been imprinted
with intense aﬁ‘ect. These inner representations develop into scenes (Kaufman 1992,
1996). The scene is the event as it is lived or experienced; affect both fuses with and
ampliﬁes the scene. Scenes surrounding the expression of affect, interpersonal needs, as
well as the sexual and hunger drives, become directly imprinted with aﬂ‘ect and then stored

in memory. Initially, events ampliﬁed with aﬂ‘ect are internalized as scenes through

33

imagery. Later, those scenes can be reactivated by new situations suﬁciently similar to
old scenes. Scenes can also become magniﬁed a process which involves the fusion and
interconnection of diﬂ‘erent but related scenes.

The process of shame internalization involves repeated association and linking of
shame directly to particular affects, drives, and needs. This results in the development of
shame binds (Kauﬁnan, 1992, 1996), the principal mechanism by which shame
internalization comes about. Whenever an experience of an affect, need, or drive is
followed by shaming, the two become linked and bound together directly in the resulting
scene. The expression of any affect, drive, or interpersonal need can in this way become
permanently linked to shame, whether deliberately or inadvertently; that linkage is created
simply by the overlap in time. Once created and internalized, the shame bind next
functions to spontaneously and indirectly activate shame in the future. Whenever any
affect, drive, or interpersonal need, which has become permanently linked to shame, is
subsequently experienced or expressed, then shame itself is spontaneously activated. The
creation of shame binds enables shame to exercise a powerful, indirect control over
behavior.

To illustrate this process, consider a boy who expresses sexual desire toward
another boy, which is typically unacceptable in contemporary society; that boy is usually
shamed for behaving in this way. When such an experience becomes bound by shame, and
these experiences become too shameful to bear, the child will eventually separate himself
from those sexual desires, ultimately disowning this shameﬁrl part of himself.
Consequently, closeted gay men who discover or become aware of reemerging parts of

themselves already bound by shame, Speciﬁcally about homosexuality, will not be able to

34

experience homoerotic feelings without also experiencing shame. The shame bind results
in shame being generated internally and now experienced directly and continually about
homosexuality. Being gay has indeed become shameful.
W

Although the development of shame binds through aﬂ‘ectively linked experiences
begins in childhood, it is by no means limited to that developmental epoch. Among People
with AIDS and also among homosexual men, the connection between Shame and
HIV/AIDS, and between shame and homosexuality, can be readily observed. Yet,
psychological distress within both the HIV+/AIDS and the homosexual populations are
often investigated by looking for the presence of depression, substance abuse, or
adjustment disorder. Instead of attempting to force these populations to ﬁt into certain
predetermined symptom categories (depression, substance abuse, adjustment disorder), a
more ﬁuitﬁrl approach would involve assessing the ﬁrndamental components embedded in
their affective experience.

prsychopathology is a disorder of the affective life as both Tomkins and Kaufman
argue, then affect itself must become the focus of inquiry. One such affective component
is shame, which is conceptualized as distinct from but certainly a precursor to disorders
such as depression or even addiction. Shame is also the affect which lies at the root of the
process of stigrnatization.

Previous research can be reinterpreted in the light of affect theory. Stigrnatizing
both HIV infected people and homosexuals results in the inhibition of their ability to freely
express their ﬁrll range of affect. Positive affect is necessarily restricted and negative

aﬂ’ect, while made more intense, is also constricted via supression. These conditions cause

35

a build-up of stress due to “backed-up affect” as well as shame. While people who are
HIV+ are, in fact, more likely to develop psychological problems, this derives ﬁ'om their
inability to freely express the full range of the primary aﬂ‘ects, whether positive or
negative. Aﬁ‘ect suppression results directly in increased stress, which can be dangerous
for the I-HV+ patient. In addition, shame is also increased as a direct consequence of HIV

illness.

36

CHAPTER 2
DESIGN OF THE CURRENT STUDY

Prior research has attempted to illuminate the range of psychological disorders
commonly experienced by People with AIDS and by homosexuals as well as the
widespread societal prejudice still confronting both groups. What has not been examined
are the speciﬁc affective responses that are triggered within the general population when
one is ﬁrst confronted by HIV/AIDS or by homosexuality. Those affective triggers and
responses must be more clearly delineated in order to fully comprehend the process of
stigrnatization. Only after these aﬂ‘ective triggers are clariﬁed can the process of working
through those aﬂ‘ects and counteracting prejudice proceed eﬁ’ectively.

This study evaluated the affective reactions of male college students when
confronted with issues related both to HIV infection and homosexuality. This was
accomplished by having each subject read one of four vignettes: The ﬁrst described a man
who has HIV+ status and is homosexual; the second, a man who has HIV+ status and is
heterosexual; the third, a man who has Leukemia and is homosexual; and the fourth, a man
who has Leukemia and is heterosexual. After reading a vignette, subjects completed
questionnaires that measure shame. Subjects completed the questionnaires twice: Once
for self and a second time as if they were answering for the person described in the
vignette. The subjects’ responses to the vignettes, which are in eﬁ‘ect their “projected”
affective experiences, were interpreted through Tomkins’s Affect theory and Kaufman’s
Shame theory.

This study utilized a 2 X 2 X 2 Repeated Measures Analysis of Variance

(ANOVA) design with Disease (Leukemia, HIV+) and Sexual Orientation (Heterosexual,

37

Homosexual), as the independent variables, and ISS scores (Self, Projected) as the Target
of the shame ratings factor.

Based on hypotheses put forth by Aﬂ‘ect Theory and Shame Theory, this study
predicted that HIV+ status would be the most signiﬁcant variable in generating shame
responses ﬁ'om subjects. The second most signiﬁcant variable for generating shame
responses was predicted to be homosexuality. Moreover, it was predicted that an
Interaction Effect would be observed when HIV+ status and homosexuality are combined:
the combination of HIV+ status and homosexuality would produce a level of shame
greater than the sum of these two parts. Theoretically, this would be true even for a man
who is comfortable and well adjusted to homosexuality because learning of his HIV+
status would trigger re-enactments of old shame scenes relating to homosexuality, ﬁrrther
combining shame, anger, fear, and disgust with homosexuality and with HIV+ status.

Hypothesis One. The ﬁrst hypothesis predicted that differences between IS S-self
and IS S-projected shame ratings would interact with Disease (Leukemia, HIV) and Sexual
Orientation (Heterosexual, Homosexual). This would be demonstrated by a signiﬁcant
3-Way Interaction. Support for this hypothesis would be ﬁrrther demonstrated by
follow-up paired samples t-tests indicating the largest increase in shame ratings between
IS S-self and ISS-projected scores when subjects rated the vignette with both HIV+ status
and Homosexuality; the second largest increase in shame ratings would be generated in
response to the vignette describing a man who has an HIV+ status and who is
Heterosexual; the third largest increase in shame ratings would be generated in response to
the vignette describing a man who has Leukemia and who is Homosexual; and the smallest

increase in shame ratings would be generated in response to the vignette describing a man

38

 

 

who

des

the
He

Ill

who has Leukemia and who is Heterosexual.

W. The second hypothesis predicted that shame on the Aﬂ‘ect
Inventory would interact with Disease (Leukemia, HIV) and Sexual Orientation
(Heterosexual, Homosexual). This would be demonstrated by a signiﬁcant 2-Way
Interaction. Support for this hypothesis would be ﬁrrther demonstrated by a Multivariate
Analysis of Variance (MAN OVA) indicating that when subjects read the vignette
describing HIV+ status and Homosexuality, the highest scores would be generated for
aﬂ‘ect adjectives that load heavily on the “Shame” sub-scale; the second highest score on
the “Shame” sub-scale would be generated for vignettes describing HIV+ status and
Heterosexuality; the third highest score on the “Shame” sub-scale would be generated for
vignettes describing Leukemia and Homosexuality; and the lowest score on the “Shame”

sub-scale would be generated for vignettes describing Leukemia and Heterosexuality.

39

CHAPTER 3
METHOD

Megs

The subjects were 131 men, the majority of whom were undergraduate students.

A student population was thought to be representative of the larger population in that
some subjects may be openly gay and some “closeted,” while the majority will be
heterosexual and healthy. Subjects either received extra credit in their courses in exchange
for their participation or were entered into a rattle for the chance to be one of four
students to win $25.00.

In deciding how many subjects to test, it would have been desirable, when
computing item analyses on newly developed measures (i.e., the Affect Inventory), to have
at least 10 subjects for each variable being tested because 10 subjects per variable would
provide a high degree of reliability in the results and permit greater generalizability of
those results. This would have required approximately 400 subjects, however, and such
an endeavor was not feasible. Instead, 131 subjects were tested and the data ﬁ'om those
subjects were interpreted cautiously.

Materials

The materials used in this study included an Informed Consent form (Appendix A),
Demographic Information Questionnaire (Appendix B), Sexual Orientation Questionnaire
(Appendix C), Current Health Status Questionnaire (Appendix D), four vignettes
describing speciﬁc characteristics of a man named “Mark” (Appendix F, G, H, I), ﬁrst and
second administrations of the ISS (Appendix E and J), Affect Inventory (Appendix K),

and a Brief Statement (Appendix L).

40

W. The Informed Consent Form stated: “This is a study which
loolm at people’s understanding and empathy toward other people who are in a situation
which is either different from your own situation or similar to your own situation. This is
a ‘norrnative study’ which means we do not currently know how normal people, such as
you, will respond, and we want you to help us ﬁnd out. It is anticipated that your
participation in this experiment will take about one hour and you will receive research
credit for your participation.” The task subjects were asked to complete are listed in the
Informed Consent: Demographic Information Questionnaire, Sexual Orientation
Questionnaire, Health Status Questionnaire, ISS Questionnaire, one vignette, Adjective
Inventory Checklist, and to write a few sentences explaining your responses.

Demogpaphic Information mestionnaire. The Demographic Information
Questionnaire requested the following information: subjects’ age, year in school,
ethnicity/race, religious identiﬁcation while growing up, current religious identiﬁcation,
and academic major. These data were used to examine possible differences among the
four subject groups that might confound tests of the research hypotheses.

Segg Orientation mestionnaire. Preliminary data was also gathered on subjects’
sexual orientation. As described by Socall (1995), the Assessment of Sexuﬂ Orientation
Sc_al_§ (Coleman, 1987) generates data on sexual orientation using a multidimensional
method. In developing this scale, Coleman augmented the “classic” Kinsey homosexual-
heterosexual continuum by expanding it from the single question used by Kinsey. A
shortened version of Coleman’s (1987) instrument was used by Socall (1995) and was
used here to gather information about subjects’ present sexual orientation identiﬁcation,

future desired sexual orientation identiﬁcation, and comfort level with current sexual

41

orientation. Also included were questions which ask about subjects’ current relationship
status, whether subjects know others who are gay, and the status of that relationship (i.e.,
friends, family, acquaintance).

Curre_nt Health Stapuﬂmtipnnpig. Information was gathered regarding
subjects’ current health status, frequency of high risk behavior for contracting HIV,
history of HIV testing, and current HIV Serostatus. Also included were questions about
HIV knowledge and personal experiences with HIV + populations.

Intemalized Shame Scaﬁ. The Intemalized Shame Scale (ISS), developed by
Cook (1994), is a 30-item self-report questionnaire that assesses the extent to which
subjects have internalized painﬁrl levels of shame. Subjects were asked to rate the
ﬁ'equency with which they experience the emotions described in each item. Ratings are
made on a 5-point Likert scale (0 = Never to 4 = Almost Always) with higher scores
representing more internalized shame. The shame scale instrument is made up of 24
negatively-worded shame items and a second scale, made up of six items, which is used to
measure “self-esteem” and to lessen the tendency for a response set to develop when all
“shame items” are worded in the same direction” (Cook, 1994).

The ISS was standardized using both clinical and non-clinical populations. The
non-clinical subject population used in the normative data sample (N = 645) comprised
undergraduate and graduate students. This sample also consisted Of both male (3 2%) and
female (68%) students. The subjects’ mean age was 24 years (SD = 8; range = 17-63),
75% were single, and approximately 86% were white, 10 % Native American, and the

remainder comprised other minorities.

42

Factor analyses of the ISS have revealed two shame factors: Inferiority and
Alienation. The Inferiority scale, however, accounts for 7 5% of the total variance and the
two scales are correlated signiﬁcantly with each other (0.77 - 0.83). Since these two
scales have a high degree of overlap, Cook (1994) has argued that the two scales probably
will not contribute diﬂ‘erential information. The ISS, therefore, is typically used as a single
scale measuring internalized shame (Cook, 1994).

Cook (1994) reported reliability data for both clinical (alpha = .96) and non-
clinical (alpha =.95) populations and reported a median item-total correlation of 0.70 in
the clinical sample and .63 in the non clinical sample.

The validity data for the ISS are offered as a comparison to other measures of
disturbances of emotional life. The data are presented this way because shame is
considered both an auxiliary affect to the positive aﬁects and also an aﬂ‘ect that is
fundamental in self-development. Therefore, shame can exert an impact on a wide range
of psychological disorders, and it has been compared to various other diagnostic
instruments.

The ISS was compared to the Brief Symptom Checklist (i.e., SCL-SO), a 50-item
version of the SCL-90 instrument. Using a sample of 336 adult out-patient psychotherapy
clients, the correlations among the ten scales of the SCL-50 (Depression, Somatic,
Obsessive-compulsive, Interpersonal sensitivity, Anxiety, Hostility, Psychoticism, Phobic
anxiety, Paranoid ideation, and Guilt), and the ISS ranged between 0.45 and 0.74, all
signiﬁcant at the p<0.01 level. These correlations “conﬁrm the pervasive role played by
shame emotions in the psychopathology of a clinical population” (Cook, 1994, p. 21).

In another validity test, the ISS was compared to the Parental Bonding Instrument

43

(PBI) developed by Parker (1983). The PBI is a 24-item scale that yields scores for the
dimensions of care (related to warmth and nurturance) and protection (related to a pattern
of intrusiveness and over-control). High scores represent either a high level of care and
nurturance or a high level of over-control and intrusiveness. Adult parents complete the
measure by remembering how their parenting was experienced during childhood.

The sample included 155 non-clinical subjects and 200 clinical subjects. The scales
were labeled “mother care,” “mother protection,” “father care,” and “father protection.”
The “direction of the correlations indicates that a high level of care and nurturance is
associated with lower shame and high control and intrusiveness is associated with higher

levels of internalized shame” (Cook, 1994). Correlations for three of the four scales

(mother care, mother protection, father protection) were signiﬁcant at ps. 01. The other

scale (father protection) was signiﬁcant at ps .05. These results suggest that the ISS has

good construct validity and also can be used to evaluate a wide range of emotional
disturbances.

When scoring the ISS, a shame score is calculated by removing the six positively
worded items (items 4, 9, 14, 18, 21, and 28) and then summing the numerical responses
to the remaining 24 items. The shame score can range from 0-96. Raw scores can then be
compared to normative data and signiﬁcant diﬂ‘erences evaluated.

Aﬂ‘eg Inventog. The Affect Inventory, a new measure, was developed and used
in this study for the ﬁrst time. The list of affects was taken from Tomkins’s and
McCarter’s (1964) list of Neutral plus eight other primary aﬂ‘ect pairs: 1) Interest —
Excitement; 2) Surprise — Startle; 3) Distress — Sad; 4) Joy — Happy; 5) Afraid —

Frightened; 6) Angry — Mad; 7) Disgusted — Loathing; 8) Shame - Humiliation. Each

44

affect was labeled to represent both low and high intensity. For example, the affect
Interest is a low-to-moderate intensity aﬂ‘ect and Excitement is the same affect at a high
intensity level (Demos, 1995, p. 218). In Tomkins’s and McCarter’s (1964) research on
the primary aﬂ‘ects, they also generated a brief list of alternative words which can be used
to signify each aﬂ‘ect. In order to test their hypothesis that these aﬂ‘ects are innate and
recognized by most people when one’s face displays the experience of any given aﬂ‘ect,
Tomkins and McCarter instructed subjects to view photographs of faces which portrayed
each primary affect. The subjects’ task was to determine which aﬁ’ect was expressed in
each photograph by selecting from a list the appropriate primary aﬂ’ect or its alternative in
order to describe the facial expression.

In general, statistically signiﬁcant results showed that subjects were successful in
matching the affect words to the appropriate facial expression. The correlations between
the primary affect and affect posed in the photograph ranged from .631 to .988 (N = 24).
These correlations suggest that these aﬂ‘ect words strongly relate to the affect presented in
the photographs. Their study utilized 40 adjectives, including those categorized as
Neutral, all of which were shown to accurately describe various displayed emotions.

In the current study, a total of thirty-six adjectives were selected, the majority of
which were taken from Tomkins’s and McCarter’s (1964) original list, along with
additional aﬂ‘ect adjectives written for this study and selected through consultation with an
expert in affect theory and shame theory.

The adjectives used here were randomly listed and placed along side a 5-point
Likert Scale (1 = never, 5 = almost always). The randomization was accomplished by

creating a list of adjectives and then placing each adjective onto its own strip of paper.

45

Next, the strips of paper were placed in a bowl and thoroughly mixed, after which one
strip was removed at a time and set aside. The ﬁrst adjective selected in this manner was
placed ﬁrst on the list. The second adjective picked was placed second, and so on. This
process was repeated until all adjectives had been selected and placed in sequence on the
list.

To complete the Affect Inventory, subjects were asked to rate the ﬁ'equency with
which they believe the man named Mark in each vignette experiences each aﬂ’ect on the
inventory. Answers were recorded on a 5-point Likert scale (1 = Never, 5 = Almost
Always) and higher scores represent more of that emotion.

Prpcedure

Prior to data collection, 131 subject packets were created and numbered 001
through 131. Packets 001 through 031 included the HIV + and homosexual vignette;
packet 032 through 062 included the HIV+ and heterosexual vignette; packet 063 through
093 included the Leukemia and homosexual vignette; and packet 094 through 131
included the Leukemia and heterosexual vignette. All packets also included the other
measures described earlier. The packets were distributed to the participants in random
order.

Subjects were tested in a group/classroom setting. Each subject was given a
packet and asked to remove its entire contents. The Informed Consent Form was on top
and all subjects were asked to read and sign the Informed Consent Form if they were
willing to participate. The Informed Consent Forms were collected and scanned for
signatures. All participating subjects were reminded that they were free to stop

participation at any time without penalty.

46

Subjects were then asked to complete the next items in their packet including the
Demographic Information Questionnaire, the Sexual Orientation Questionnaire, and the
Current Health Status Questionnaire.

The ISS was completed next. The directions were read aloud by the experimenter
and the subjects were instructed to complete the ISS. This scale was used to measure the
subjects’ own level of internalized shame.

Next, subjects were asked to read the vignette in their packet and complete the
second ISS form, this time answering the questions as if they were reporting how the man
in the vignette, Mark, actually feels. After the second ISS was completed, all subjects
completed an Aﬂ’ect Inventory. Finally, subjects were asked to write a few short
sentences reporting why they believe “Mark” feels the way he does.

After all measures were completed, subjects were asked to replace all of their
forms in the packet folder and their folders were collected. A debrieﬁng period followed,
and any questions were answered at that time.

Data Analysis

All statistical procedures were performed using the Statistical Package for Social
Science (SPSS) and only ﬁndings resulting in pg .05 were considered signiﬁcant.
General Statistical Procedures

Frequencies and descriptive statistics were generated for all data recorded on the
Demographic, Sexual Orientation, and Current Health Status questionnaires (see
Appendix M for details). Additionally, in order to examine whether subjects in each group
were comparable on the data collected via the Demographic, Sexual Orientation, and

Current Health Status questionnaires, a One-Way Analysis of Variance (ANOVA) across

47

all groups was computed.

Data Analysis for Hypothesis One. To test the 3-Way-Interaction between Disease
(Leukemia, HIV+), Sexual Orientation (Heterosexual, Homosexual), and ISS scores (Self,
Projected), a Repeated Measures Analysis of Variance was computed using Disease
(Leukemia, HIV+) and Sexual Orientation (Heterosexual, Homosexual) as
between—subject variables, and ISS scores (Self, Projected) as Target of shame ratings
factor.

Data Angysis for the Aﬂ‘ect Inventog; and Hypothesis Two. Because the Aﬂ‘ect
Inventory is a new instrument, a Principal Components Analysis (PCA) was computed.
Inter-item correlations, inter-scale correlations, mean-item correlations, and variances
were calculated. Any items that decreased reliability on sub-scales were evaluated and, if
warranted, dropped from further analyses. Following this, an Exploratory Factor Analysis
using the PCA solutions was computed.

Next, two Multivariate Analyses of Variance (MAN OVAS) were used to analyze
the data related to the second hypothesis. The ﬁrst MANOVA evaluated the possible
Interaction Effect between Disease (Leukemia, HIV), Sexual Orientation (Heterosexual,
Homosexual), and the six Negative Adjective sub-scales. The second evaluated the
possible Interaction between Disease (Leukemia, HIV), Sexual Orientation (Heterosexual,

Homosexual), and the two Positive Adjective sub-scales.

48

CHAPTER 4
RESULTS

Demo a hic Information

A One-Way Analysis of Variance (AN OVA) was computed across all using the
Demographic, Sexual Orientation, and Current Health Status Questionnaires, to assess
possible differences between each group of subjects. Groups were deﬁned by
experimental condition. Group one comprised subjects who read the vignette identifying
Mark as a homosexual and as diagnosed HIV+; Group two comprised subjects who read
the vignette identifying Mark as a heterosexual and as diagnosed HIV+; Group three
comprised subjects who read the vignette identifying Mark as a homosexual and as
diagnosed with Leukemia; and Group four comprised subjects who read the vignette
identifying Mark as a heterosexual and as diagnosed with Leukemia (see Appendix M for
descriptive statistics).

One signiﬁcant difference was found between groups. Signiﬁcantly more subjects
who identiﬁed their “race”as nonwhite on the Demographic Questionnaire were in Group
one compared to any other group. Therefore, analyses were computed to determine the
extent, if any, of the relationship between the Demographic variable Race and ISS ratings.
The results showed that Race did not have a signiﬁcant eﬂ’ect on ISS ratings F(1, 123), =
.28, p = .6.

Results of Primary Predictions

Results for Hypothesis One. The ﬁrst hypothesis predicted a 3-Way-Interaction

between Disease, Sexual Orientation, and ISS ratings, the Target of shame ratings factor.

The 3-Way-Interaction was not signiﬁcant E(1, 109) = .041, p = .84. Only the Main

49

Effect for Target of shame ratings factor was signiﬁcant _E(l, 109) = 29.17, p = .000,

indicating signiﬁcant differences between ISS-self scores and IS S-projected scores across

 

_al_l_ vignette conditions (see Table 1).

Neither of the 2-Way interactions, between Disease and Target or between Sexual
Orientation and Target, were signiﬁcant. However, there was a signiﬁcant difference
between group effects for Disease that was not predicted _E(l, 109) = 8.32, p = .005. In
other words, both Leukemia and HIV+ status produced signiﬁcant increases in ISS-
projected scores compared to IS S-self scores. Another ﬁnding surprisingly showed that
bo_th ISS-self and IS S-projected group ratings were lower, meaning less shame, for the
groups reading vignettes describing Leukemia t = (129) = -2.04, p = .043, than for the
groups reading vignettes describing HIV+ status _t_ = (126.4) = -1.91, p = .058, even
though subjects had been randomly assigned to each condition. AS seen in Table 1,
however, the diﬂ‘erence in mean scores between IS S-Self and IS S-Projected scores was
not signiﬁcantly different between groups.

Analysis of the Affect Inventogy & Results for Hypothesis Two. Hypothesis two
posited that a 2-Way Interaction between Disease (Leukemia, HIV) and Sexual
Orientation (Heterosexual, Homosexual) would be found for Affect Inventory adjectives
loading heavily on shame. Furthermore, the rank order predicted for Hypothesis One was
also predicted to be generated by the Affect Inventory. In other words, the highest score
on the “Shame”sub-scale would be generated for vignettes describing HIV+ status and
Homosexuality; the second highest score on the “Shame”sub-scale would be generated for
vignettes describing HIV+ status and Heterosexuality; the third highest score on the

“Shame” sub-scale would be generated for vignettes describing Leukemia and

50

Homosexuality; and the lowest score on the “Shame” sub-scale would be generated for
vignettes describing Leukemia and Heterosexuality.

Before testing this hypothesis, a Principal Component Analysis was computed to
reduce the Affect Inventory data. Originally, nine sub-scales including Distress (4-items,
alpha = .77), Anger (4-items, alpha = .83), Dissmell (4-items, alpha = .84), Disgust (4-
items, alpha = .85), Afraid (4-items, alpha = .85), Shame (4-items, alpha = .89), Joy (4-
items, alpha = .86), Interest (4-items, alpha = .77), and Surprise (4-items, alpha = .57),
were used in the analysis. In two instances, sub-scale items were dropped because they
reduced some sub-scale’s internal reliability. The dropped items were “Aggression” ﬁom
the “Anger sub-scale” and “Lonely” from the “Distress sub-scale.” Also, the entire sub-
scale “Surprise” was dropped since it was internally inconsistent. After dropping the two
unreliable adjectives, and dropping the sub-scale “Surprise,” the overall internal
consistency and reliability of the Affect Inventory had Sub-scale Alpha Coefficients
ranging from 0.77 to 0.89 and each item had a Corrected Item-Total Correlation of .50 or
above. Table 2 shows Sub-scale Alpha Coefﬁcients and Corrected Item-Total
Correlations for each item, including those items and scales that were dropped. Table 3
shows the correlation matrix for the remaining eight sub-scales.

The remaining eight sub-scales were Factor Analyzed using an Exploratory Factor
Analysis and two Factors were found. Table 4 shows the sub-scale loadings for each
factor. The ﬁrst factor, called the Negative Aﬂ‘ect Factor, included six sub-scales; 1)
Distress, 2) Angry, 3) Dissmell, 4) Disgust, 5) Aﬁ'aid, 6) Shame. The second factor,
called the Positive Affect Factor, included two sub—scales; 1) Joy and 2) Interested.

Following this to test Hypothesis Two, a MANOVA was performed using the six

51

sub-scales associated with the Negative Affect Factor (Distress, Angry, Dissmell, Disgust,
Afraid, Shame) as dependent variables, and Disease (Leukemia, HIV), and Sexual
Orientation (Heterosexual, Homosexual) as independent variables. This analysis did not
support the second research hypothesis; the 2-Way Interaction between Disease and
Sexual Orientation was not signiﬁcant (Wilks’ Lambda H6, 116), = .73, p = .63). In
addition, neither of the two Main Effects was signiﬁcant. Similarly, no signiﬁcant effects
resulted from the second 2 X 2 MAN OVA, substituting the two sub-scales from the
Positive Affect Factor (Joy, Interested) as dependent variables (Wilks’ Lambda E(2, 120),

= .262, p = .77). Table 5 shows Aﬂ‘ect Inventory mean scores for each group.

52

 

 

 

1.5!. .. ... finial!
.r.

 

CHAPTER 5
DISCUSSION

Through the lens of Affect Theory and Shame Theory, this study evaluated the
aﬂ‘ective reactions of college men when confronted with issues related to HIV infection
and homosexuality. Two predictions were investigated, neither of which were supported.
However, after submitting the Affect Inventory to an Exploratory Factor Analysis of the
Principal Component Analysis’ solutions, the Affect Inventory was found to have
statistically sound construction. Also, unanticipated signiﬁcant results pertaining to
subjects’ reactions to the variable Disease were discovered, as well as unexpected subject-
selection ﬁndings.

Discussion of the Affect Inventog

The Aﬂ‘ect Inventory is a modiﬁed list of adjectives taken from Tomkins et al.
(1964). Although this study was not primarily intended to create a new measure of affect,
it has nevertheless served to create a measure which, as others have hypothesized, (Socall,
1995; Tomkins, 1962; Watson & Tellegen, 1985; Zevon & Tellegen, 1982), clearly
identiﬁed two primary affective states, Negative and Positive. The Negative Adjective
factor is comprised of six sub-scales describing negative affects (i.e., Distressed, Afraid,
Angry, Disgusted, Shame, Dissmell) and the Positive Adjective factor is comprised of two
sub-scales describing positive aﬂ‘ects (i.e., Joy, Interested).

As shown in Table 3, the correlations between the sub-scales Shame, Dissmell, and
Disgust are particularly strong. This implies that subjects did not perceive the adjectives
within these sub-scales as different ﬁ'om each other. These sub-scales, therefore, did not
discriminate the subjects’ affective reactions. This is an important issue when determining

the strength of the Affect Inventory in a research setting. In the future, one may choose to

53

~«-u.ili

 

lL- _ . ..

 

COl

WC

combine adjectives from these sub-scales and attempt to add an additional sub-scale which
would discriminate affective reactions more effectively.

However, the lack of discrimination makes sense when considered within the ‘
context of Affect Theory and Shame Theory. Tomkins (1987), Kaufman (1996), and
Kaufman and Raphael (1996) believe that Dissmell and Disgust are emotions which lead
to the experience of Shame, are “shame-based” adjectives, and are intimately connected
to the experience of Shame. It is possible therefore, that the clinician trained in Affect
Theory and Shame Theory would readily identify the differences between Disgust,
Dissmell, and Shame, while those who are less focused on the nuances of aﬂ‘ective
experiences would not readily identify the differences. This issue is worthy of
consideration when the Affect Inventory is used in ﬁrture research.

Nevertheless, the Aﬂ‘ect Inventory reliably identiﬁes adjectives which express
feelings associated with shame. This is signiﬁcant because one drawback of earlier
attempts to understand and explore shame was the lack of an appropriate language with
which to describe shame (Tomkins’s, 1962; Kaufman, 1992, 1996; Kauﬁnan & Bly, 1995;
Kauﬁnan & Raphael, 1991, 1996). The Affect Inventory, as developed here, furthers our
ability to understand shame by crystallizing a language that captures this elusive emotion
and this sets the stage for ﬁrrther exploration. Also, one of the adjectives included in the
Affect Inventory (i.e., Dissmell) which applies to the shame construct as Kauﬁnan has
outlined (1996), was found to correlate highly with other adjectives that are thought to be
shame-based, as well as with the adjective “shame” itself (.74) (see Table 3). As Kaufman
(1996) states, Dissmell is deﬁned by Tomkins (1987) as an “innate defensive response,

ﬁrnctioning in an auxiliary manner to the oxygen, thirst, and hunger drives” (p. 13).

54

Dissmell serves to protect human beings from noxious objects via a facial reaction of
raising the upper lip and nose, while simultaneously drawing-back the head, thereby
reducing one’s closeness from noxious smelling stimuli. Dissmell is a distancing, rejecting
aﬂ‘ect. Since Dissmell is shown here to be correlated with the aﬂ‘ect of shame, it is
assumed that Dissmell played a role in subjects’ shame-based responses, especially toward
Disease. Given the close association between disease and contamination, this makes
theoretical sense.

Also, although the diﬂ‘erences were not signiﬁcant, the Affect Inventory Mean
scores produced a rank order consistent with the predicted results (see Table 5). Since
these ﬁndings failed to reach signiﬁcance, and because this measure is new, the results
must be interpreted cautiously and must be independently replicated. Still, the Affect
Inventory oﬂ‘ers new opportunities to examine shame and therefore it warrants future
research consideration.

Discussion of the Prima_ry Prﬂiction

Hyppthesis One. The ﬁrst hypothesis predicted a 3-Way-Interaction between
Disease (Leukemia, HIV), Sexual Orientation (Heterosexual, Homosexual), and ISS
ratings (Self, Projected), the Target of shame ratings factor. The ﬁndings did not support
this hypothesis. The assumption underlying this hypothesis was that the stimulus value of
conﬁonting a person who is HIV+ and Homosexual would produce shame in the subjects,
leading them to project their shame onto the person with the undesirable characteristics,
and thereby stigrnatize the individual possessing these characteristics. Based on a
combination of Goffrnan’s Stigrnatization Theory (1963), Tomkins’s Affect Theory

(1962), and Kauﬁnan’s Shame Theory (Kaufman, 1992, 1996; Kaufman & Bly, 1995;

55

Kauﬁnan & Raphael, 1991, 1996), this should have been true even for subjects with high
levels of internalized shame (i.e., ISS-self score) because even those who experience high
levels of internalized shame should be able to place distance between themselves and
others whom they view as outside of “normal.”

In this study, subjects did express higher levels of projected shame, as measured by
the ISS, compared to internalized shame, also measured by the ISS (see Table 2).
Subjects did not, however, appear to project shame based on speciﬁc Diseases or speciﬁc
Sexual Orientations. Although the 3-Way-Interaction was not signiﬁcant, there was a
signiﬁcant ﬁnding for the Main Effect Disease. Again, this showed that both Leukemia
and HIV + status produced signiﬁcant increases in ISS-projected scores compared to ISS-
self scores.

There are multiple reasons why subjects who participated in this study experienced
high levels of shame toward disease in general, but did not speciﬁcally attribute shame to
people who are HIV+. One explanation could be related to the fact that many of the

subjects are too young to remember a time when HIV/AIDS did not exist. The average

age of the subjects in this study was almost 21-years ( [.1835 20.72) and the modal age was

19-years. When the ﬁrst signs of the AIDS illness were becoming known to hospitals in
the United States in 1979 (Curran, 1983), and the ﬁrst AIDS related deaths were reported
by the CDC in 1981 (Batchelor, 1984; Nicholas, 1983), many of these subjects had not yet
been born. It is possible that, having grown up during a time when HIV/AIDS has always
been a known entity reduces one’s perception of “difference” about HIV+ people
compared to others who are seriously ill with a different disease.

Another explanation for an increased and generalized shame response to disease

56

might be related to an unexpected impact of the characteristics describing Marla the man
in the vignettes. Mark was intentionally described using characteristics with which many
college students could identify. Although the vignettes were designed with the intention
to increase the subject’s identiﬁcation with Mark, it was not anticipated that subjects’
reactions would be the same for all vignettes. Although all subjects read vignettes which
described a man who ultimately regained his health sufﬁciently to continue his daily living,
the illnesses were described as “serious” and it is assumed that participants recognize that
HIV and Leukemia are both potentially fatal. For most people, thinking about death
evokes intense emotional experiences. As Kaufman (1996) suggests, death is thought to
be “the universal symbol of ultimate human powerlessness” (p. 53) and thus, death is a
potential activator of distress and shame. Moreover, people in their early twenties do not
Often consider their own mortality; young people often “feel invincible.” Ifthese
assumptions are valid, then the subjects’ unexpected confrontation with descriptions of a
potentially fatal disease affecting someone they could identify with may have changed their
experience toward the HIV and Leukemia variables; death may have dominated their
emotional experiences, leading subjects to “ignore” the type of illness and react only to the
potential outcome.

Unexpected Grpup Differences. Unexpectedly, subjects who ultimately read

vignettes describing Leukemia had lower mean IS S-self scores (msgselfmmm = 24.17,
alss_sclfmm0mup 4 = 20.90) than subjects who ultimately read vignettes describing HIV+

status mlssxmmupl = 26.48, Missﬂmmoupz = 29.47). For more details, see

Table 1. This ﬁnding is perplexing given that all subjects were randomly assigned to

groups. Moreover, as shown in Appendix M, all groups were similar when compared on

57

Demographic, Sexual Orientation, and Current Health Status Questionnaires.
Brief Statement

Subjects were also instructed to “Describe why you think the man in the vignette,
Mark, feels the way the way he does.” Although subjects’ responses in their Brief
Statement were reviewed, they were not analyzed. Subjects put forth a variety of reasons
for their projected responses. Some speciﬁcally wrote that Mark felt “shame” for being

gay, some assumed AIDS was transmitted through homosexual encounters, even when

Mark was identiﬁed as a heterosexual (i.e., lover was Roberta) and others expressed anger
as a dominant affect experienced by Mark. Often, the anger was directed toward his
disease, which may translate into the increased likelihood for a young death. Still, others
expressed sympathy for Mark having HIV and having Leukemia, depending on the
vignette they read. No group patterns were readily identiﬁable regarding either Sexual
Orientation or Disease.
Future Rpsearch

Affect Inventog. Future investigations may beneﬁt from using the Affect
Inventory twice for each person. When considering the beneﬁts of the ISS data collected
for this study, the decision to use pre - and post -- data allowed for the evaluation of
aﬁ‘ective change over time, an impossible analysis with only one set of data. One could
easily mimic this study’s approach to ISS data collection, but also include the Affect
Inventory early in the process, collecting an Affect Inventory-self rating in addition to an

Affect Inventory-projected rating.

58

W. On the Aﬂ‘ect Inventory, ﬁndings revealed non-
signiﬁcant diﬂ‘erences between group means, although the mean scores did follow the
hypothesized rank order suggesting a possible trend. Although it may not be feasible for
many researchers, one suggestion for ﬁrture research would be to increase statistical
power by dramatically increasing the number of subjects in each group. Increasing power
may indeed yield signiﬁcant results.

Vigpettes. What may be more feasible than attracting more subjects, however,
would be to increase the effect size of the vignettes. In other words, by more clearly
distinguishing each variable, one may get more distinct responses. This could be
accomplished by clarifying the vignette descriptions of Sexual Orientation and Disease and
offering clearer and more descriptive statements about each Sexual Orientation and about
each Disease. Since this study was predicated on the idea that subjects would respond to
the Sexual Orientation and Disease variables, identifying these variables more directly and
discussing them more expansively ought not to adversely change the integrity of the study.
For example, instead of using the names “Robert and Roberta” to identify Mark’s lover
and thus identify his Sexual Orientation, one could choose more clearly distinct names like
“Alan and Stacy.” Alternatively, one could make a direct reference to Mark’s Sexual
Orientation by openly labeling him homosexual or heterosexual and also use more explicit
names to identify his lover. In clarifying the Disease variables, one could describe
common symptoms, identify common routes of transmission, and specify the way in which
the person in the vignette contracted their respective diseases. Caution should be taken,
however, to try and minimize diﬁ‘erences between variables. For example, if the

description of the HIV+ person is that of an IV drug user who contracted HIV from

59

sharing dirty needles, one might have a diﬂ‘erent reaction to that person compared to the
person who contracts Cancer through contamination resulting ﬁom a chemical spill.
Similarly, diﬂ'erent feelings may be evoked toward the HIV+ person who contracted the
Virus ﬁ'om their HIV+ mother while in utero compared to the IV drug user. Using more
similar examples, such as contracting HIV through sharing dirty needles and contracting
Lung Cancer from smoking two packs of non-ﬁltered cigarettes per day may help balance
the vignettes.

Additionally, one could choose to add a different type of “control vignette” to the
study. For instance, a vignette could be inserted after the self-rating of the ISS which
would identify Mark as both heterosexual and healthy. The original vignettes could
remain the same or be modiﬁed in ways described above. One might expect multiple
levels of shame to be produced; one for self, one for Mark when he is deﬁned as
heterosexual and healthy, and a third and fourth depending on the Sexual Orientation and
Disease status of the subsequent vignettes.

Finally, while the demographic variable “religion” did not impact the results
reported in the current study, it may nevertheless be useful to include a Religiosity
Questionnaire. By doing so, one could more clearly determine whether different levels of
religious beliefs impact ratings. It might be predicted that the more explicit the vignettes
are in describing sexual orientation issues, routes of transmission, and other details and
deﬁnitions, the more likely one’s conservative or liberal biases would inﬂuence aﬁ‘ective
reactions and thus ratings. It may be useful to have information related not only to one’s
religious preference, but also to understand the possible impact of the level of religious

connection.

60

 

W. The characteristics of subjects who are chosen to participate in
ﬁrture studies need to be considered. Perhaps most clinically interesting would be to
include an additional group of male subjects who are either HIV+ or homosexual.
However, if the results of such a study were to produce results similar to those presented
here, one could argue that the projections made in this study were accurate, even though
the hypotheses were not supported. If the results were signiﬁcantly diﬁ‘erent when HIV+
men or homosexual men were the subjects, not only would the current ﬁndings be less
meaningﬁrl, but new information regarding the feelings of people who actually deal with
these issues would then be available. This is additionally important because understanding
the inner experience of individuals is a necessary part of any clinical undertaking.

Another group that could shed new light on this topic would be female subjects.
This would require adding vignettes which have females experiencing the same problems
as Mark. Also, female testers should be considered, to balance any possible effect ﬁom
sex-diﬂ‘erences resulting from the sex of the tester. The beneﬁts of such changes may
outweigh the challenges. For instance, because homophobia continues to be a problem in
our culture, and tends to be more problematic for men than women, having women
participate may lead to more information about sex differences when confronting
homosexuality in men.

The possibilities for ﬁrture research in the area of stigrnatization of homosexuals
and People with HIV/AIDS are considerable. Further research is important in order to
expand knowledge of the processes involved in stigrnatization. It is also important in
order for therapists to have a more effective impact working with these clients and anyone

struggling with these issues.

61

 

Clinical Implications

The clinical implications of this and similar research relate directly to clinicians’
ability to work effectively with homosexuals, HIV+ people, and others who are in contact
with these individuals. Since 1973 when the American Psychological Association
removed homosexuality from the list of disorders in the DSM (Morin & Rothblum,
1991), research focusing on psychologists’ and medical staffs’ willingness to provide
services to homosexuals and HIV+ people shows a continuing pattern of stigrnatization
toward those populations (St. Lawrence, Kelly, Owen, & Hogan, 1990; Kelly, St.
Lawrence, Smith, Hood, & Cook, 1988; Kelly, St. Lawrence, Smith, Hood, & Cook,
1987a; Kelly, St. Lawrence, Smith, Hood, & Cook, 1987b). Still other researchers have
noted that the mental health profession’s stigrnatizing practices often create iatrogenic
wounds when serving these clients while Simultaneously limiting the chances that these
people would continue to seek basic services readily available to others. Finally, when
HIV+ people experience stress, their immune system may suffer irreparable damage, and
failing to help these peOple reduce their stress adds an additional burden to their condition.
This strongly indicates the need for increased understanding, through research, of the
counter-transference experienced when professionals are confronted with homosexuality
and HIV-infected people. If we do not actively pursue knowledge about the unwarranted
prejudice communicated by professionals, we not only fail to help this population but we
also risk creating additional harm.

There are still other important reasons for professionals to further their insight into
their own counter-transference reactions and into the needs of these two groups. One of

the most useful approaches to working with the issues faced by HIV+ people is through

62

support groups (Ruhala & Woodring, 1993; Sherr, 1995). Compared to individual
therapy, the group oﬂ‘ers an opportunity to serve many clients at one time, often
accommodating as many as twelve individuals. One of the reported beneﬁts of these
support groups is the opportunity to meet with others without concern about being treated
as an outcast (i.e., stigmatized) and without the need to explain one’s condition, risking
problematic responses. If, however, psychologists are less willing to facilitate this type of
group, thereby limiting the number of groups available, many will suffer ﬁ'om limited
access to services.

Additionally, where HIV is concerned, the results generated by this type of
research would extend beyond helping individuals who are HIV+. In recent years, many
mental health agencies have recognized the need to oﬂ‘er services to family members,
spouses/partners, and care givers ofHIV+ people. There are now support groups for
Couples who are Sero-discordant (one partner HIV+, one partner HIV—); for Family and
Friends of HIV+ people; for Grandparents Raising HIV+ Grandchildren; and for HIV+
Care Givers (AIDS Resource Guide, Baltimore, 2000). These groups have reported
tremendous diﬁculty maintaining client membership. One possible reason for diminished
attendance may relate to the facilitators’ limited understanding of the speciﬁc affects
generated when people are confronted with HIV. Since precise aﬂ‘ective reactions to HIV
are still unknown, it is possible that group leaders are not able to easily understand the
inner experience of their group members. When misunderstandings are recognized but no
satisfying remedies are available, then a clinical impasse is easily reached, which has been
hypothesized to lead to dropping out (Dr. Anne Yenchko, personal communication,

September 4, 2000). The research presented here, therefore, is not limited to helping

63

People with HIV/AIDS, but impacts all of the people living with and working with issues
related to HIV/AIDS.

One last clinical implication relates to the way in which medical knowledge and
treatment regimes alter the societal impact of HIV/AIDS and also vicariously impact
homosexual communities. The medical information available concerning HIV/AIDS,
coupled with the speed with which new information is generated, increases the likelihood
that HIV/AIDS will become a chronic, manageable illness, similar to diabetes and high
blood pressure. Iftreatrnent of HIV/AIDS were to reach this stage, but many
professionals continued to be resistant to working with this population, then the perceived
need to attend to people with this illness will remain low and this could provide an excuse
for continued under-involvement by mental health professionals. This would be an
unfortunate outcome. If psychologists continue to resist working with this population, the
clinical implications will almost certainly result in increased death rates for HIV+/AIDS
populations.

Conclusions

Although this study did not produce signiﬁcant results, the lack of signiﬁcance
does not necessarily mean that such evidence is absent. Instead, these ﬁndings should
encourage researchers to redouble their efforts to ﬁnd the data that will explicate the
attitudes of many people in society toward People with HIV/AIDS, as expressed by
Buckley Jr. (1986) and Robinson (1987), and the present research ﬁndings. Additionally,
some data suggests that homosexuals are perceptively connected to HIV/AIDS (Brauer,
1994; Bennet, 1987; Crandall, Glor, & Britt, 1997; DeMarco, 1998; Herek & Glunt,

1988, 1991; Kaufman, 1996; Kauﬁnan & Raphael, 1996; Limandri, 1989; Morin, Charles,

64

Maylon, 1984; Morin & Rothblum, 1991), increasing the need to better understand and
work more effectively with this population as well.

The Aﬂ‘ect Inventory is a promising new measure for studying shame because it
appears to accurately identify shame-based aﬂ‘ect. In this study, the Aﬁ‘ect Inventory was
easy to administer, easy to score, and appeared statistically sound. Nevertheless, because
it is new additional research is necessary to further validate both its useﬁrlness and
statistical construction.

Theoretically driven research, in this case the guiding theories put forth by
Tomkins, Kauﬁnan, and Goﬂinan, is particularly useful because it oﬂ‘ers the unique
contribution of a language that most accurately describes shame. It must be left to ﬁxture
research to clarify and substantiate how these theories best apply to HIV and to

homosexuality.

65

 

 

 

APPENDIX A

APPENDIX A

Informed Consent

This is a study which looks at peoples’ understanding and empathy toward other
people who are in a situation which is either different from our own situation or similar to
our own situation. This is a “normative study” which means we do not currently know
how normal people, such as you, will respond, and we want you to help us ﬁnd out. It is
anticipated that your participation in this experiment will take about 20-25 minutes and for
your participation I will include $5.00 as a token of my appreciation.

Ifyou choose to participate in this study, you will be one subject out of a total of
approximately 120. All subjects’ records will be kept conﬁdential. To ensure this, you
will be assigned a subject number, which will be the only way to identify you in any
reports about this study. Only the experimenter will have access to the ﬁles and lists
which could be used to link a name with a subject number. Any publications from this
work will not identify you by name or in any way that would allow your identity to be
discovered.

For this study you will be asked to complete several tasks.

1. On the Subject Identiﬁcation Form, you will be asked to write your name.

This is the only form that can identify you by name and link you to the subject
identiﬁcation number that has been assigned to you. Only the experimenter and his
designates will have access to your ﬁle. To ensure conﬁdentiality, all other documents you
ﬁll out will have only your subject identiﬁcation number.

2. On the Demographic Information Questionnaire, you will be asked to provide

66

 

’- CV'lh - 3v:

APPENDIX A (con’t)

your age, ethnicity, religion, years of education, and academic major.

3. On the Sexual Orientation Questionnaire, you will be asked to provide
information about your current sexual orientation identiﬁcation; your future desired sexual
orientation identiﬁcation; how comfortable you are with your current sexual orientation;
current relationship status; and whether you know people who are gay and, if so, the
nature of your relationship to them.

4. On the Health Status Questionnaire, you will be asked to provide information
about high risk sexual behavior; whether you have been tested for HIV serostatus; if so,
when you were and what the results were; whether you know anyone who is or was
HIV+; and what their current health status is, and the nature of their relationship to you.

5. On the ISS, you will be asked to complete a questionnaire which asks how
often you experience certain feelings.

6. Next you will be asked to read one of four vignettes. Each vignette describes a
person and includes a variety of characteristics. After reading the vignette you will be
asked to complete another ISS. The questionnaire will ask you to decide how often you
think the subject in the vignette experiences certain feelings/aﬂ‘ects.

7. Next you will be asked to complete an Adjective Inventory. The instructions
for this measure will ask that you decide how often you think the subject in the vignette
experiences certain feelings/affects.

8. Then you will be asked to write a few sentences explaining why you think the

person in the vignette feels the way he does.

67

APPENDIX A (con’t.)

A debrieﬁng period will follow your participation in the experiment. You will
receive one hour of research credit for your participation. You have the right to
discontinue your participation at any time and for any reason, and to do so without
explanation or penalty. There is also an alternative method of earning extra course credit if
you do not wish to participate in this or other experiments. Ifyou wish to seek this
alternative, speak with your Introductory Psychology professor for speciﬁcs. The
assignment may vary from professor to professor, but it usually involves writing a short
paper.

Ifyou would like further information regarding your rights as a research subject,
you may contact the Ofﬁce of the UCRIHS at Michigan State University by telephoning
(517) 355-2180.

After the entire study is completed, if you have any questions or if you want a
written summary of the general results, you may contact the investigator at his university

ofﬁce.

 

I have read this consent form, I understand the conditions, and I voluntarily agree to

 

 

 

 

participate in this study.
Subject’s Signature Date
Investigator’s Signature Date

68

APPENDIX B

APPENDIX B

 

SUBJECT DEMOGRAPHICS
1) Age: _
2) Ethnic or Racial Identiﬁcation:
__ Black/Aﬁican American _ Hispanic, Chicano, Latino, or Mexican
American
__ White or Caucasia __ Asian/Oriental/Paciﬁc Islander
_ Native American _ Other
(specify)
3) Highest Level of Education:
__ Less than High School diploma __ High School diploma
_ Some college, no degree _ Bachelor’s degree
__ Associates degree _ Masters, professional degree or
Beyond

4) If you were raised with a speciﬁc religious preference, what religion was it?

 

Catholic Protestant Jewish Buddhist
Muslim Presbyterian Hindu None
Other

(Please Specify)

5) With which religion do you currently identify, if any?

 

Catholic Protestant Jewish Buddhist
Muslim Presbyterian Hindu None
Other

(Please specify)

69

APPENDIX B (Con’t.)

6) What is your Academic Major?

 

Psychology Engineering
Hotel/Restaurant Management Forestry
Other

(Please specify)

70

Business

Education

 

APPENDIX C

APPENDIX C
SEXUAL ORIENTATION DATA
1) In terms of my present sexual orientation, 1 identify myself as . . .

__ Exclusively homosexual

__ Predominantly homosexual
_ Bisexual

_ Predominantly heterosexual
_ Exclusively heterosexual

Unsure

2) In my future, I would like to identify myself as . . .
_ Exclusively homosexual

-__ Predominantly homosexual

_ Bisexual

__ Predominantly heterosexual

__ Exclusively heterosexual

Unsure

3) In terms of comfort with my current sexual orientation, 1 would say that I am . . .
Very comfortable Mostly Comfortable Comfortable

Not very comfortable Very Uncomfortable

71

APPENDIX C (con’t.)

4) What is your current relationship status?

_ Single, no sexual partners

__ Single, one committed partner

__ Single, multiple partners

_ Coupled, living together (Committed to an exclusive sexual relationship)

__ Coupled, living together (Relationship permits other sexual partners under certain
circumstances)

Coupled, living apart (Committed to an exclusive sexual relationship)

Coupled, living apart (Relationship permits other sexual partners under certain
circumstances)

_ Other (please specify)

 

5) Do you know people who are gay?

Yes No
5a) If yes, are they your . . .
Family Member Friend Acquaintance Other

72

APPENDIX D

APPENDIX D
CURRENT HEALTH STATUS

1) How many times have you engaged in “high risk sexual behavior” with a woman (i.e.,
having sexual intercourse without using a condom)?

Otimes betweenlandStimes between6and10times
between 11 and 15 times between 16 and 20 times morethan 20 times

2) How many times have you engaged in “high risk sexual behavior” with a man (i.e., having
sexual intercourse without using a condom)?

_Otimes _betweenlandStimes _between6and10times
_between 11 and 15 times _between 16 and 20 times _morethan20 times
3) Have you ever been tested for the Human Immunodeﬁciency Virus (HIV)?

Yes No

4) If you have been tested for HIV, when was your last test performed?

within the last 3 months between 3 months and 6 months ago
between 6 months and 12 months ago between 12 months and 24 months ago
over 24 months ago

5) Did the results show that you are/were . . .
__ HIV positive __ HIV negative
_ Unclear results
6). Do you currently know or have you known in the past anyone who is HIV+?
___ Yes _ NO
6a) If yes, how close do you feel you are/were to that person?

Very close Somewhat close Acquaintance

Not particularly close Not close at all

73

APPENDIX D (cou’t)

7) Islwas that person a member of your immediate family?

Yes NO

7a. If yes, was it your. . .

 

Mother Father Brother Sister
Aunt Uncle Other
(Please SpecifY)

8) What is that person’s current health status?

 

Alive and physically well Alive but with failing health
Died ﬁ'om HIV/AIDS related Died of something unrelated to
medical issues HIV/AIDS
Other

(Please Specify)

74

APPENDIX E

APPENDIX E

Intemalized Shame Scale

Directions: Below is a list of statements describing feelings or experiences that you may have had
from time to time or that is familiar to you because you may have had these feelings and
experiences for a long time. Most of these statements describe feelings or experiences that are
generally painful or negative in some way. Some people will seldom or never have some of these
feelings. Everyone has had some of these feelings at some time. Ifyou ﬁnd that these statements
describe the way you feel a good deal of the time, it can be painful just reading them. Try to be as
honest as you can in responding.

Read each statement carefully and circle the number to the right of the item that indicates the
frequency with which you ﬁnd yourself feeling or experiencing what is described in the
statement.

 

 

 

 

 

 

 

 

 

 

 

 

Almost
Never Seldom Sometimes Frequently Always
1.1feelthatlamneverquite l 2 3 4 5
good enough.
2. I feel somehow left out. 1 2 3 4 5
3. I think that people look down on me. 1 2 3 4 5
4.Allinall,laminclinedtofeelthatl 1 2 3 4 5
am a success.
5. I scold myself and put myself down. 1 2 3 4 5
6. I feel insecure about others opinion 1 2 3 4 5
of me.
7. Compared to other people I feel like 1 2 3 4 5
I somehow never measure up.
8. I see myself as very small 1 2 3 4 5
and insigniﬁcant.
9. I feel I have much to be proud of. l 2 3 4 5
10. I feel intensely inadequate and l 2 3 4 5
full of self-doubt.
11. I feel as if I am somehow defective l 2 3 4 5
as a person, like there is something
basically wrong with me.

75

APPENDIX E (con’t.)

 

 

 

 

 

 

 

 

 

 

 

 

 

Almost
Never Seldom Sometimes Frequently Always

12. When I compare myselfto others 1 l 2 3 4 5
am just not as important.

13. I have an overpowering dread that 1 2 3 4 5
my faults will be revealed in front
of others.

14. I feel I have a number ofgood 1 2 3 4 5
qualities.

15. I see myself striving for perfection I 2 3 4 5
only to continually fall short.

16. Ithinkothersareabletosee my 1 2 3 4 5
defects.

17. I could beat myself over the head 1 2 3 4 5
with a club when I make a mistake.

18. On the whole, I am satisﬁed with l 2 3 4 5
myself.

19. I would like to shrink away when I 1 2 3 4 5
make a mistake.

20. I replay painful events over and l 2 3 4 5
over in my mind until I am
overwhehned.

21.1feellamapersonofworthat l 2 3 4 5
least on an equal plane with others.

22. At times I feel like I will break into 1 2 3 4 5
a thousand pieces.

23. I feel as if I have lost control over 1 2 3 4 5
my body functions and my feelings.

24. Sometimes I feel no bigger than a l 2 3 4 5

 

pea.

76

25.

26.

27.

28.

29.

30.

APPENDIX E (cou’t.)

 

 

 

 

 

 

Almost

Never Seldom Sometimes Frequently Always
At times I feel so exposed that I 1 2 3 4 5
wish the earth would open up and
swallow me.
Ihave this painﬁrlgapwithin me 1 2 3 4 5
that I have not been able to ﬁll.
I feel empty and unfulﬁlled. l 2 3 4 5
I take a positive attitudes toward 1 2 3 4 5
me myself.
My loneliness is more like. 1 2 3 4 5
emptiness.
I feel like there is something 1 2 3 4 5
missing.

77

APPENDIX F

APPENDIX F
Vignette

Mark, a 20-year-old college student at a large Midwestern university, is a hard
working student studying computer programing. Mark is an outgoing person who has
lived on campus since he arrived at college, although he is currently thinking about moving
to an oﬁlcampus apartment. His interests include surﬁng the Internet, going to movies
and pubs, and he has many sports related interests as well.

Over the last few months Mark has been experiencing a number of health-related
problems. These have included fatigue, physical decline such as weight loss, poor
appetite, and restless sleep, as well as recurrent infections. When Mark went to his
doctor, he found out that he was seriously ill; He was diagnosed as having Human
Immunodeﬁciency Virus (HIV +).

Mark’s family, including his mother, father, older sister, and older brother had a
diﬁicult time dealing with his illness. Also, even though it was difficult to see Mark not
feeling well, the seriousness of Mark’s illness drew his longstanding romantic partner,
Robert, even closer to him.

Although he took ﬁve years, Mark went on and ﬁnished college, receiving a degree
in computer programing. Mark is still HIV +, but with medication and continued support
ﬁ'om Robert he can continue to engage in those things he always enjoyed: surﬁng the

Internet, going to movies and pubs, and sports.

78

APPENDIX G

APPENDIX G

Vignette

Mark, a 20-year-old college student at a large Midwestern university, is a hard
working student studying computer programing. Mark is an outgoing person who has
lived on campus since he arrived at college, although he is currently thinking about moving
to an Oﬂlcampus apartment. His interests include surﬁng the Internet, going to movies
and pubs, and he has many sports related interests as well.

Over the last few months Mark has been experiencing a number of health-related
problems. These have included fatigue, physical decline such as weight loss, poor~
appetite, and restless sleep, as well as recurrent infections. When Mark went to his
doctor, he found out that he was seriously ill; He was diagnosed as having Human
Immunodeﬁciency Virus (HIV+).

Mark’s family, including his mother, father, older sister, and older brother had a
diﬁcult time dealing with his illness. Also, even though it was diﬂicult to see Mark not
feeling well, the seriousness of Mark’s illness drew his longstanding romantic partner,
Roberta, even closer to him. Although he took ﬁve years, Mark went on and ﬁnished
college, receiving a degree in computer programing. Mark still has HIV+, but with
medication and continued support from Roberta he can continue to engage in those things

he always enjoyed: surﬁng the Internet, going to movies and pubs, and sports.

79

APPENDIX H

APPENDIX H

Vignette

Mark, a 20-year-old college student at a large Midwestern university, is a hard
working student studying computer programing. Mark is an outgoing person who has
lived on campus since he arrived at college, although he is currently thinking about moving
to an oﬂ‘-campus apartment. His interests include surﬁng the Internet, going to movies
and pubs, and he has many sports related interests as well.

Over the last few months Mark has been experiencing a number of health-related
problems. These have included fatigue, physical decline such as weight loss, poor
appetite, and restless sleep, as well as recurrent infections. When Mark went to his
doctor, he found out that he was seriously ill; He was diagnosed as having Leukemia
(cancer).

Mark’s family, including his mother, father, older sister, and older brother had a
diﬂicult time dealing with his illness. Also, even though it was difficult to see Mark not
feeling well, the seriousness of Mark’s illness drew his longstanding romantic partner,
Robert, even closer to him. Although he took ﬁve years, Mark went on and ﬁnished
college, receiving a degree in computer programing. Mark still has Leukemia, but with
medication and continued support from Robert he can continue to engage in those things

he always enjoyed: surﬁng the Internet, going to movies and pubs, and sports.

80

APPENDIX I

APPENDIX I

Vignette

Mark, a 20- year-old college student at a large Midwestern university, is a hard
working student studying computer programing. Mark is an outgoing person who has
lived on campus since he arrived at college, although he is currently thinking about moving
to an oﬂlcampus apartment. His interests include surﬁng the Internet, going to movies
and pubs, and he has many Sports related interests as well.

Over the last few months Mark has been experiencing a number of health-related
problems. These have included fatigue, physical decline such as weight loss, poor
appetite, and restless sleep, as well as recurrent infections. When Mark went to his
doctor, he found out that he was seriously ill; He was diagnosed as having Leukemia
(cancer).

Mark’s family, including his mother, father, older sister, and older brother had a
difficult time dealing with his illness. Also, even though it was diﬂicult to see Mark not
feeling well, the seriousness of Mark’s illness drew his longstanding romantic partner,
Roberta, even closer to him. Although he took ﬁve years, Mark went on and ﬁnished
college, receiving a degree in computer programing. Mark still has Leukemia, but with
medication and continued support from Roberta he can continue to engage in those things

he always enjoyed: surﬁng the Internet, going to movies and pubs, and sports.

81

APPENDIX J

APPENDIX J

Intemalized Shame Scale

Directions: Below is a list of statements describing feelings or experiences that you may have had
from time to time or that is familiar to you because you may have had these feelings and
experiences for a long time. Most of these statements describe feelings or experiences that are
generally painful or negative in some way. Some people will seldom or never have some of these
feelings. Everyone has had some of these feelings at some time. Ifyou ﬁnd that these statements
describe the way you feel a good deal of the time, it can be painful just reading them. Try to be as
honest as you can in responding.

Read each statement careﬁrlly and circle the number to the right of the item you think Mark, the
man in the vignette, experiences what is described in the statement.

 

 

 

 

 

 

 

 

 

 

 

Almost
Never Seldom Sometimes Frequently Always
1. I feel that I am never quite 1 2 3 4 5
good enough.
2. I feel somehow left out. 1 2 3 4 5
3. I think that people look down on me. 1 2 3 4 5
4.Allinall,IaminclinedtOfeelthatl 1 2 3 4 5
am a success.
5. I scold myself and put myself down. 1 2 3 4 5
6. I feel insecure about others opinion 1 2 3 4 5
of me.
7. Compared to other people I feel like 1 2 3 4 5
I somehow never measure up.
8. I see myself as very small 1 2 3 4 5
and insigniﬁcant.
9. I feel I have much to be proud of. l 2 3 4 5
10. I feel intensely inadequate and l 2 3 4 5
full of self-doubt.
11. I feel as if I am somehow defective l 2 3 4 5
as a person, like there is something
basically wrong with me.

82

APPENDIX J (con’t)

 

 

 

 

 

 

 

 

 

 

 

 

 

Almost
Never Seldom Sometimes Frequently Always

12. When I compare myselfto others I l 2 3 4 5
am just not as important.

13. I have an overpowering dread that l 2 3 4 5
my faults will be revealed in ﬂoat
of others.

14. I feel I have a number of good 1 2 3 4 5
qualities.

15. I see myself striving for perfection I 2 3 4 5
only to continually fall short.

16.1thinkotbersareabletoseemy 1 2 3 4 5
defects.

17. I could beat myself over the head 1 2 3 4 5
with a club when I make a mistake.

18. On the whole, I am satisﬁed with 1 2 3 4 5
myself.

19. I would like to shrink away when I l 2 3 4 5
make a mistake.

20. I replay painful events over and l 2 3 4 5
over in my mind until I am
overwhelmed.

21.1feellarnapersonofworthat 1 2 3 4 5
least on an equal plane with others.

22. At times I feel like I will break into 1 2 3 4 5
a thousand pieces.

23. I feel as if I have lost control over 1 2 3 4 5
my body functions and my feelings.

24. Sometimes I feel no bigger than a 1 2 3 4 5
pea.

83

 

APPENDIX J (con’t)

25.

26.

27.

28.

29.

30.

Almost

Never Seldom Sometimes Frequently Always
At times I feel so exposed that I 1 2 3 4 5
wish the earth would open up and
swallow me.
Ihavethispainfulgapwithin me 1 2 3 4 5
that I have not been able to ﬁll.
I feel empty and unfulﬁlled. l 2 3 4 5
I take a positive attitudes toward 1 2 3 4 5
me myself.
My loneliness is more like. 1 3 4 5
emptiness.
I feel like there is something 1 3 4 5
missing.

 

 

 

 

 

 

34

APPENDIX K

APPENDIX K

Affect Inventory

Directipns: Below is a list of words which describe affects or feelings. Please read each
word carefully and circle the number to the right of the word that indicates the ﬁ'equency
with which you think the subject in the vignette you just read experiences the affect
described here. Use the scale below and try to be as accurate as you can in responding.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Almost

Never Seldom Sometimes Frequently Always
1. Aggressive 1 2 3 4 5
2. Alert 1 2 3 4 5
3. Contaminated 1 2 3 4 5
4. Panicky 1 2 3 4 5
5. Terriﬁed l 2 3 4 5
6. Delighted 1 2 3 4 5
7. Disgusting 1 2 3 4 5
8. Smiling 1 2 3 4 5
9. Pained l 2 3 4 5
10. Excited l 2 3 4 5
11. Frightened 1 2 3 4 5
12. Loathing 1 2 3 4 5
13. Amazed 1 2 3 4 5
14. Smelly 1 2 3 4 5
15. Scornful 1 2 3 4 5
16. Angry 1 2 3 4 5

 

 

85

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

36.

Surprised
Petriﬁed
Soiled
Inferior
Attentive
Distressed
Sad
Joyful
Revolting
Exposed
Startled
Polluted
Worthless
Focused
Lonely
Furious
Shocked
Hostile
Pleased

Humiliated

Never
1

APPENDIX K (con’t)

 

 

1

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Almost
Seldom Sometimes Frequently Always
2 3 4 5
2 3 ' 4 5
2 3 4 5
2 3 4 5
2 3 4 5
2 3 4 S
2 3 4 5
2 3 4 5
2 3 4 5
2 3 4 5
2 3 4 5
2 3 4 5
2 3 4 5
2 3 4 5
2 3 4 5
2 3 4 5
2 3 4 5
2 3 4 5
2 3 4 5
2 3 4 5

86

APPENDIX L

APPENDIX L
Brief Statement

In the space provided, please describe why you think the man in the vignette, Mark, feels
the way he does?

 

 

 

 

 

 

 

 

 

87

APPENDIX M

APPENDIX M

Descriptive Statistics for Demographic Questionnaire Variables

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WHAT IS YOUR AGE?
Subjects Age Frequency % of Total Subjects
18 11 8.40
19 3 1 23 .70
20 29 22.10
21 26 19.80
22 22 16.80
23 4 3.10
24 2 1.50
25 2 1.50
26 l 0.80
3 1 1 0.80
34 1 0.80
36 1 0.80
ETHNIC/RACIAL IDENTIFICATION?

Race Frequency % of Total Subjects
Black\Aﬁican-American 6 4.60
Hispanic\Chicano\Latino\ 3 2.30
Mexican-American

White\Caucasian 96 73.30
Asian\Paciﬁc Islander 19 14.50
Native American 0 0.00
Other 7 5.30

 

 

 

 

88

 

 

APPENDIX M (Con’t)

Descriptive Statistics for Demographic Questionnaire Variables

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LEVEL OF EDUCATION?

Education Frequency % of Total Subjects
Less than High School 1 0.80

High School Diploma 8 6.10

Some College/No Degree 94 71.80

Associates Degree 4 3.10

Bachelor’s Degree 21 16.00
Masters/Professional 3 2.30

Degree

RELIGIOUS BACKGROUND?

Religious Background Frequency % of Total Subjects
Catholic 46 3 5. 10

Protestant 29 22. 10

Jewish 11 8.40

Buddhist 2 1.50

Muslim 2 1.50

Presbyterian 6 4.60

Hindu O 0.00

None 22 16.80

Other 13 9.90

 

 

 

 

 

89

 

APPENDIX M (Con’t.)

Descriptive Statistics for Demographic Questionnaire Variables

CURRENT RELIGIOUS PREFERENCE?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Religious Background Frequency % of Total Subjects
Catholic 29 , 22. 10

Protestant 22 16.80

Jewish 11 8.40

Buddhist 4 3.10

Muslim 2 1.50

Presbyterian 5 3.80

Hindu 0 0.00

None 38 29.00

Other 20 1 5 . 30

ACADEMIC MAJOR?

Major Frequency % of Total Subjects
Psychology _ 13 9.90

Engineering 25 19.10

Business 17 13.00
Hotel\Restaurant 2 l .50

Management

Forestry 2 1.50

Education 1 0.80

Other 71 54.20

 

 

 

 

 

9O

APPENDIX M (Con’t.)

Descriptive Statistics for Sexual Orientation Questionnaire Variables

CURRENT SEXUAL ORIENTATION?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Sexual Frequency '/o of Total Subjects
Orientation

Exclusively Homosexual 1 0. 80

Predominantly Homosexual 2 1.50

Bisexual 2 1.50

Predominantly 12 9.20

Heterosexual

Exclusively Heterosexual 113 86.30

Unsure 1 0.80

DESIRED SEXUAL ORIENTATION?

Desired Sexual Frequency % of Total Subjects
Orientation

Exclusively Homosexual l 0.80

Predominantly Homosexual 2 1.50

Bisexual 2 1.50

Predominantly 13 9.90

Heterosexual

Exclusively Heterosexual 113 86.30

Unsure 0 0.00

 

 

 

 

91

 

 

APPENDIX M (Con’t.)

Descriptive Statistics for Sexual Orientation Questionnaire Variables

COMFORT W/CURRENT SEXUAL ORIENTATION?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Comfort w/ Current Sexual Frequency '/o of Total Subjects

Orientation

Very Comfortable 115 87.90

Mostly Comfortable 9 6.90

Comfortable 6 4.60

Not Very Comfortable 0 0.00

Very Uncomfortable 1 0.80
CURRENT RELATIONSHIP STATUS?

Relationship Status Frequency '/o of Total Subjects

Single, No Sexual Partners 76 58.00

Singe, One Committed Partner 25 19.10

Single, Multiple Partners 5 3.80

Coupled, Living Together 5 3.80

(Committed to an Exclusive Sexual

Partner)

Coupled, Living Together 0 0.00

(Relationship Permits Other Sexual

Partners Under Certain

Circumstances)

Coupled, Living Apart, (Committed 17 13.00

to One Sexual Partner)

Coupled, Living Apart (Relationship 1 0.80

Permits Other Sexual Partners Under

Certain Circumstances)

Other 2 1.50

 

 

 

 

92

 

 

APPENDIX M (Con’t.)

Descriptive Statistics for Sexual Orientation Questionnaire Variables

DO YOU KNOW PEOPLE WHO ARE GAY?

 

 

 

Know Gay People Frequency '/o of Total Subjects
Yes 106 80.60
No 25 19.10

 

 

 

 

 

IF YOU DO KNOW PEOPLE WHO ARE GAY, ARE THEY YOUR?

 

 

 

 

 

 

 

Who Do You Know Frequency % of Total Subjects
Family Member 13 9.90
Friend 57 43.50
Acquaintance 36 27.50
Other 25 19.10

 

 

 

93

APPENDIX M (Con’t.)

Descriptive Statistics for Current Health Status Questionnaire Variables

HIGH RISK SEXUAL BEHAVIOR WITH WOMEN?

 

 

 

 

 

 

 

 

 

 

 

High Risk w/Women Frequency % of Total Subjects
0 times 70 53.40
Between 1 & 5 Times 36 27.50
Between6& 10 Times 4 3.10
Between 11 & 15 Times 3 2.30
Between 16 & 20 Times 2 1.50
More than 20 Times 16 12.20

 

 

HIGH RISK SEXUAL BEHAVIOR WITH MEN?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

High Risk w/Men Frequency % of Total Subjects
0 times 128 97.70
Between 1 & 5 Times 1 0.80
Between 6 & 10 Times 1 0.80
Between 11 & 15 Times 0 0.00
Between 16 & 20 Times 0 0.00
More than 20 Times 1 1.80
HAVE YOU EVER BEEN TESTED FOR HIV?
HIV Test Frequency % of Total Subjects
Yes 25 19.10
No 106 80.90

 

 

 

 

 

94

APPENDIX M (Con’t.)

Descriptive Statistics for Current Health Status Questionnaire Variables

 

 

 

 

 

RESULTS FROM HIV TEST?
HIV Status Frequency % of Total Subjects
Never Been Tested 108 82.40
HIV+ 0 0.00
HIV — 22 16.80
Unclear Results 1 0.80

 

 

 

 

 

DO YOU KNOW CURRENTLY OR HAVE YOU KNOWN IN THE PAST
ANYONE WHO IS HIV+?

 

 

 

 

 

Know HIV+ People Frequency % of Total Subjects
Unanswered 13 9.90
Yes 12 9.20
No 105 80.20

 

 

 

 

 

HOW CLOSE DO YOU FEEL YOU ARE/WERE TO THE HIV+ PERSON?

 

 

 

 

 

 

 

 

Closeness Frequency % of Total Subjects
Unanswered 116 88.50
Very Close 2 1.50
Somewhat Close 3 2.30
Acquaintance 3 2.30
Not Particularly Close 3 2.30
Not Close at All 3 2.30

 

 

 

 

95

APPENDIX M (Con’t.)

Descriptive Statistics for Current Health Status Questionnaire Variables

IS/WAS THE HIV+ PERSON A MEMBER OF YOUR IMNIEDIATE F AMEY?

 

 

 

 

Family Member Frequency % of Total Subjects
Unanswered 1 19 90. 80
Yes 0 0.00
No 12 9.20

 

 

 

 

 

IF THEY WERE A FAMILY MEMBER, WERE THEY YOUR?

 

 

 

 

 

 

 

 

 

Relative Frequency % of Total Subjects
Unanswered 129 97.90
Mother 0 0.00
Father 0 0.00
Brother 0 0.00
Sister 0 0.00
Aunt 0 0.00
Uncle 0 0.00
Other 2 1.50

 

 

 

 

 

96

Descriptive Statistics for Current Health Status Questionnaire Variables

APPENDIX M (Con’t.)

WHAT IS THE PERSON’S CURRENT HEALTH STATUS?

 

 

 

 

 

 

 

 

 

 

Current Health Frequency '/o of Total Subjects
Unanswered 119 91.60

Alive & Physically Well 5 3 .80

Alive but w/F ailing Health 1 0.80

Died from HIV/AIDS 5 3.80

Related Illness

Died from Something 0 0.00

Unrelated to HIV/AIDS

Other 0 0.00

 

 

97

«a

 

Table 1: Mean scores for Intemalized Shame Scale-Self ratings and Projected ratings and

the Amount of Change between scores.

Intemalized Shame Scale Scores

 

 

 

 

 

 

 

 

 

 

Group N ISS-Self ISS-Projected Difference
1 42 26.48 37.57 11.09
2 30 29.37 39.37 10.00
3 29 24.17 35.93 11.76
4 30 20.90 29.80 8.90

 

Note: For ISS-Projected Mean Scores, Group 1 = Homosexual & HIV+;

Group 2 = Heterosexual & HIV+; Group 3 = Homosexual & Leukemia;
Group 4 = Heterosexual & Leukemia.

98

 

Table 2. Aﬂ‘ect Inventory Sub-scale, Adjectives, Corrected Item-Total Correlations, and
Sub-scale Alpha scores.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sub-Scale Headings & Corrected Item-Total Sub-Scale Alpha Scores
Aﬂ’ect Adjectives Correlations
DISTRESSED .77
Distressed .49
Sad .69
Pained .57
bonely :‘3'6
AFRAID .85
Panicky .56
Frightened .75
Petriﬁed .71
Terriﬁed .73
ANGRY .83
Angry .63
Furious .64
Hostile .58
Aggressive £3
DISGUST .85
Loathing .68
Disgusting .63
Scornful .71
Revolting .77

 

 

 

 

 

99

Table 2. (Continued)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SHAME .89
Inferior .80
Exposed .66
Humiliated .81
Worthless .77
DISSMELL .84
Smelly .63
Soiled .73
Polluted .77
Contaminated .58
INTERESTED .77
Excited .56
Attentive .68
Alert .50
Focused .55
JOY .86
Joyful .71
Smiling .73
Pleased .73
Delighted .68
SURPRISE!) :57
Surprised 75-1-
Startled 739
Amazed 71-7
Shocked .‘3'8

 

 

 

 

 

Note: Strike-out lines indicate adjectives and data dropped from subsequent analyses.

100

Table 3: Correlation Matrix for eight Affect Inventory Sub-Scale headings.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Distress Angry Dissmell Joy Disgust Interest Afraid Shame
Distress 1.00 .69 .59 - .49 .64 — .39 .76 .60
Angry .69 1.00 .63 — .46 .79 - .36 .67 .70
Dissmell .59 .63 1.00 — .50 .71 — .37 .60 .74
Joy — .49 — .46 — .50 1.00 — .52 .72 — .34 — .57
Disgust .64 .79 .71 - .52 1.00 - .40 .63 .82
Interest — .39 — .36 — .37 .72 — .40 1.00 — .28 - .41
Afraid .76 .67 .60 - .34 .63 — .28 1.00 .62
Shame .60 .70 .74 - .57 .82 - .41 .62 1.00

 

101

 

Table 4. Component Matrix of factor loadings on the two factor solution revealed by
an Exploratory Factor Analysis of the Aﬂ‘ect Inventory.

 

 

 

 

 

 

 

 

 

 

 

 

Variables Negative-Adjective Positive-Adjective
Factor Factor

Distress .82 . 16

Angry .85 .21

Dissmell .82 . 10

Joy — .70 .61

Disgust .88 .13

Interest - .59 .72

Afraid .78 .36

Shame .87 6.34SE-02

 

102

 

Table 5: Mean scores and Standard Deviations on the Negative-Affect Factor of the

 

 

 

 

 

Aﬂ‘ect Inventory.
Group N Mean Score Standard
Deviation
1 42 109.00 14.21
2 30 107.73 16.76
3 29 105.21 15.52
4 30 102.40 14.54

 

 

 

 

 

Note: Group number corresponds to vignette scenarios; Group 1 = Homosexual
& HIV+; Group 2 = Heterosexual & HIV+; Group 3 = Homosexual &
Leukemia; Group 4 = Heterosexual & Leukemia.

103

 

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