An intervention to address feelings of shame and guilt related to survival based behavior after (sexual) assault.

Research shows that up to 67% of children and adolescents under the age of 16
experience at least one traumatic event during their life (Copeland et al.,
2007). A traumatic event is defined as *an event in which the subject was
exposed to actual or threatened death, serious injury, and/or sexual
assault* (American Psychiatric Association, 2013). Such a traumatic event can
result in post-traumatic stress disorder (PTSD). A meta-analysis of Alisic et
al. (2014) shows that 16% of children and adolescents develop PTSD symptoms
after experiencing a traumatic event. Alisic and colleagues also show that the
prevalence range for children and adolescents who develop PTSD as a result of
interpersonal trauma (including violence and sexual abuse) is above average.
Prevalence rates for PTSD are between 16.8% and 35.8% among children and
adolescents who have experienced violence or sexual abuse.
Experiencing violence and/or sexual abuse can be accompanied by high levels of
agony. Children and adolescents who develop PTSD, suffer from re-experiences of
the event, avoid places that remind them of the trauma, are constantly in a
state of hypervigilance and develop negative thoughts and feelings. These
negative thoughts and feelings, such as guilt and shame, are often related to
how a person reacted during and after the traumatic event (Verlinden, 2014).
When experiencing a traumatic event, such as (sexual) violence, the defense
cascade is activated (van Minnen, 2017). The defense cascade is a continuum of
survival-based reflexive and automatic reactions that the body activates in
life-threatening situations (Kalaf et al., 2017). A common example is that
someone feels like he or she *freezes* during a traumatic event. This is also
referred to as *tonic immobility* (Kalaf et al., 2017). Research shows that 21
to 70% of victims report tonic immobility as a perceived defense response
during violence (Bovin et al., 2008; Galliano et al., 1993; Hagenaars, 2016;
Heidt et al., 2005; Möller et al., 2017). However, there are multiple defense
responses besides the well-known *fight-flight-freeze*-responses. Yet, these
other responses are often misunderstood. Based on a recently conducted
literature review, 21 responses within the defense cascade appear to play a
role during and after (sexual) violence (van Minnen, 2017).
Victims often link an affective and/or cognitive response to the defense
cascade. This can be protective (*I did what I could*, *this should never have
happened to me*, etc.). Yet, often this response is the opposite (*I wish I had
asked for help*, *why didn*t I push myself away* or *why didn*t I run away*)
(Kleim et al., 2013). Negative interpretations of one's own defense responses
lead to feelings of guilt and shame. Research by Pugh et al. (2015) shows that
such interpretations play a role in the development and maintenance of
trauma-related symptoms.
The amount of guilt and shame also depends on perceived personal involvement
(Lee et al., 2001; Pugh et al., 2015). In a study of traumatized children and
adolescents, 43% had feelings of guilt in response to the traumatic event. In
children exposed to traumas of an interpersonal nature (e.g. war, maltreatment
or sexual abuse), this percentage was 59% (Fletcher, 2003). Children and
adolescents (5-16 years) who have been victims of interpersonal violence and
who have feelings of guilt about whether or not they acted *right* during the
trauma experience more PTSD symptoms (Kletter et al., 2009).
Although the defense cascade is used to increase the chance of survival and
should considered as an automatic biological response, victims are less likely
to seek help because of the guilt and shame they feel following their defense
response to the trauma (Galliano et al., 1993; van Minnen, 2017). Research
shows that only 50% of the people with PTSD symptoms seek professional help
(Roberts et al., 2011). These feelings of shame and guilt also have a negative
influence on a successful course of treatment (Kealy et al., 2018). In
addition, many victims are unaware of their defense cascade, which increases
the feeling of guilt and shame (van Minnen, 2017). These factors withhold
victims to seek help.

The present study proposes to investigate the On(t)schuldig intervention. The
main research question: Do adolescents report less trauma-related feelings of
shame and guilt after following the intervention On(t)schuldig?

This study is designed as a randomized clinical trial (RCT). Participants will
be randomized into two conditions: 1) direct access into intervention
On(t)schuldig, or 2) a waiting-list period of two weeks, after which
participants will also get access to the intervention. Over a period of eight
weeks, there are three time points where participants are asked to fill in a
number of questionnaires.

The intervention has the form of a psycho-education, which is placed on a
private website that the participants can visit using their own login code. The
psycho-education consists of three parts:
1. Animations explaining 8 common defense responses that can occur during and
after (sexual) violence;
2. Written texts based on the book *Verlamd van Angst*;
3. Podcasts with in-depth explanations about defense responses, supplemented
with interviews with adolescents who have experienced these responses
first-hand.

There is no, or very little, risk for patients with regard to participation in
the current study.

In order to answer the research question participants will be asked to fill in
questionnaires. The extra burden is considered low, as they can fil in self
reported questionnaires online. It will take about 30 minutes per measurement
to participate