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The fusion of the two emotions in research investigation has led to a lack of clarity about which emotion is being measured or explored. However, this may also suggest that there is a relationship between guilt and shame that requires further exploration. Indeed, Tangney and Dearing (2002) refer to maladaptive guilt as a term used to reflect the potential fusion or overlap between guilt and

shame. However, it is also important to recognise that findings within the current review suggest that the consequences of both guilt and shame appear to be qualitatively different promoting the need for research endeavours that attempt to clarify these concepts.

There appeared to be more research exploring the self-conscious emotion of guilt within the current review. This may in part be owing to the very nature of shame as a hidden emotion prompting social withdrawal. This may also be due to the exploration of guilt for researchers, and the disclosure of guilt for caregivers being more acceptable than the emotion of shame in relation to a relative with dementia.

1.5.1.5. Methodology Issues

In view of the conceptual confusion apparent in this research area it is important to consider how best to clarify the current evidence and enhance the robustness of future research in this area. It appears that further qualitative research may be best placed to explore the conceptualisation of guilt and shame in more detail. This would allow a broadening out of research enquiry to include exploration of the complexities and nuances in the experience of guilt and shame for dementia caregivers. Due to weaknesses in clarity of some qualitative methodologies, more explicit methodological process would be beneficial, whilst qualitative research questions with a more specific focus on guilt and shame would offer more depth to research investigation.

The quality of quantitative research was also varied. One weakness found was in relation to measures used to investigate the self-conscious emotions, which appeared to relate to how the emotions had been conceptualised. However, the CGQ offers the most promise regarding the assessment of the emotion of guilt (Losada et al., 2010). Furthermore, quantitative research was most adept at revealing further information regarding relationships to other factors and in relation to the screening and monitoring of self-conscious emotions. This line of research enquiry needs to be maintained.

It was notable that there was a very limited amount of data offered in relation to sample characteristics such as length of time caregivers had been caring,

ethnicity and severity of dementia. This is important to comment on as the variance within these factors could result in implications to the heterogeneity of the sample considered in this review.

1.5.2. Research implications

The current review suggests that whilst tentative conclusions can be drawn from the developing literature, there are a number of areas in relation to the experience of self-conscious emotions in the dementia caregiver that require further research attention. These include:

• The theoretical and conceptual understanding of guilt and shame • The potential interaction between guilt and shame

• The impact of disturbance to social reciprocity concerning an experience of guilt and/or shame

• Protective factors that might mediate against the negative impact of guilt and/or shame

• The links between guilt and/or shame in relation to clinical symptoms • The link between the stage of dementia and an experience of guilt and/or

shame

• The potential for guilt to be socially reparative in the dementia caregiving relationship

1.5.3. Clinical implications

1.5.3.1. Clinical assessment

The current review indicates that clinical practitioners are more likely to hear expressions of guilt rather than shame from caregivers. However, whilst this may be the case, practitioners should be encouraged to attend to the whole experience of the caregiver as guilt may harbour feelings of shame that may be more difficult for caregivers to express and for clinicians to identify.

Furthermore, normalising the experience of guilt and shame within the caregiving relationship may support caregivers to talk about these feelings.

1.5.3.2. Clinical intervention

Within one-to-one therapeutic interaction with caregivers, it is important to offer a non-judgemental space that offers the potential to recognise, contain and talk

about feelings of guilt and shame. Indeed, it is only once feelings are disclosed, that possible interventions can be considered.

The findings of the current review lend support to clinical interventions aimed at enhancing self-compassion and raising awareness of self-criticism, such as compassionate mind training and mindfulness (Gilbert & Proctor, 2006; Gilbert & Irons, 2005; Kabat-Zinn, 1994). Furthermore, such interventions may be of particular relevance considering the ruminatory processes linked to guilt and in view of the link to depression (Segal, 2002).

Shame and guilt appeared to be associated with social withdrawal, which may have deleterious effects for both the caregiver and the PwD. The value of connecting caregivers to socially available, inclusive and supportive networks and groups is highlighted, in order to maximise the potentially positive effects of the value of social connectedness.

The positive impact of an increase in leisure activity was also highlighted in the current review (Romero-Moreno et al., 2013). Engaging caregivers in positive, meaningful activity may offer an accessible coping strategy that protects against depressive symptoms. Importantly, the benefits of behavioural activation may be greater for those caregivers who are experiencing higher levels of guilt in relation to their own self care.