Guilt is commonly reported by trauma survivors and has been linked to greater posttraumatic stress disorder (PTSD) severity (e.g., Bryan et al., 2015). As such, understanding how guilt impacts PTSD recovery has been of significant interest to clinicians and researchers. Indeed, there has been debate about whether prolonged exposure therapy (PE) is as effective for those with high guilt, with some suggesting that imaginal exposure to trauma memories is either unhelpful (e.g., Grunert, Weis, Smucker, & Christianson, 2007) or potentially iatrogenic (e.g., Pitman et al., 1991). However, most studies have shown that baseline guilt severity does not predict PTSD recovery during PE (e.g., Clifton et al., 2017). This pattern is consistent with findings of a recent study of military personnel with PTSD reported in the Journal of Traumatic Stress (McLean et al., in press). We found that baseline trauma-related guilt did not predict reductions in PTSD symptoms for PE delivered daily or weekly, or for a non-trauma-focused comparator, present-centered therapy (PCT), delivered weekly. This suggests that both trauma-focused and non-trauma focused evidence-based treatments for PTSD may work well across levels of guilt. If replicated, the clinical implication of these findings is that patients’ guilt at pre-treatment need not influence providers’ decisions about which treatment to implement.
If high levels of guilt are not a contraindication of PE in terms of PTSD outcomes, then the next logical question is whether PE improves guilt outcomes relative to alternative treatments. Some prior studies show that cognitive processing therapy (CPT; Resick & Schnicke, 1992) is superior to PE in reducing guilt (e.g., Nishith, Nixon, & Resick, 2005). In our study with military personnel, we found that all study conditions (both formats of PE, PCT, and minimal attention control [MCC]) led to significant reductions in guilt. This finding was surprising; we expected the active treatment conditions (PE and PCT) to outperform MCC, which involved 4 weeks of 15-minute therapist phone check-ins. This finding seems to suggest that guilt improves as much from evidence-based PTSD treatment as it does from minimal support and attention. However, a key caveat to these findings is that mild to moderate guilt was overrepresented in the military sample. Although this contrasted with the study therapists’ impressions of the patients’ guilt, baseline self-reported trauma-related guilt was low, which limited our ability to evaluate change overall as well as the distinctions between conditions. As such, conclusions about the impact of high guilt on PTSD outcomes following PE and PCT and the efficacy of these treatments in ameliorating guilt will require replication in samples where higher guilt is better represented.
Understanding the role of guilt in treating PTSD is highly relevant to those who work with military personnel. Many service members are exposed to traumatic events that evoke guilt, including events that involve perpetrating, failing to prevent, and bearing witness to acts that transgress moral beliefs and expectations (Litz et al., 2009). For instance, some service members report symptoms of PTSD related to perpetrating acts of violence toward insurgents, which is sometimes accompanied by guilt. Others suffer with guilt from situations wherein a non-combatant was killed for failing to follow the instructions of a service member under direct orders to secure an area. In some cases, service members perceive their guilt to be justified, whereas in others, the guilt is objectively unjustified but equally pervasive and painful. While the results of McLean et al (in press) suggest that guilt does not impact PTSD outcomes, and that both PE and PCT ameliorates guilt, it will be important for future research to evaluate how guilt impacts treatment among military personnel reporting high levels of guilt, as well as to test whether effects are moderated by the type of trauma experienced.
Bryan, C. J., Roberge, E., Bryan, A. O., Ray-Sannerud, B., Morrow, C. E., & Etienne, N. (2015). Guilt as a mediator of the relationship between depression and posttraumatic stress with suicide ideation in two samples of military personnel and veterans. International Journal of Cognitive Therapy, 8, 143–155. https://doi.org/10.1521/ijct.2015.8.2.143
Clifton, E. G., Feeny, N. C., & Zoellner, L. A. (2017). Anger and guilt in treatment for chronic posttraumatic stress disorder. Journal of Behavior Therapy and Experimental Psychiatry, 54, 9–16. https://doi.org/10.1016/j.jbtep.2016.05.003
Grunert, B. K., Weis, J. M., Smucker, M. R., & Christianson, H. F. (2007). Imagery rescripting and reprocessing therapy after failed prolonged exposure for posttraumatic stress disorder following industrial injury. Journal of Behavior Therapy and Experimental Psychiatry, 38, 317–328. https://doi.org/10.1016/j.jbtep.2007.10.005
Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29, 695–706. https://doi.org/10.1016/j.cpr.2009.07.003
McLean, C. P., Zandberg, L., Brown, L., Zang, Y., Benhamou, K., Dondanville, K. A., Yarvis, J., Litz, B. T., Mintz, J., Young-McCaughan, S., Peterson, A. L., Foa, E. B., & the STRONG STAR Consortium. (2019). Guilt in the Treatment of PTSD Among Active Duty Military Personnel. Journal of Traumatic Stress. https://doi.org/10.1002/jts.22416
Nishith, P., Nixon, R. D., & Resick, P. A. (2005). Resolution of trauma-related guilt following treatment of PTSD in female rape victims: A result of cognitive processing therapy targeting comorbid depression? Journal of Affective Disorders, 86, 259–265. https://doi.org/10.1016/j.jad.2005.02.013
Resick, P. A., & Schnicke, M. K. (1992). Cognitive processing therapy for sexual assault victims. Journal of Consulting and Clinical Psychology, 60, 748–756. https://doi.org/10.1037//0022-006x.60.5.748
McLean, C. P., Zandberg, L. , Brown, L. , Zang, Y. , Benhamou, K. , Dondanville, K. A., Yarvis, J. S., Litz, B. T., Mintz, J. , Young‐McCaughan, S. , Peterson, A. L., Foa, E. B. and , (2019), Guilt in the Treatment of Posttraumatic Stress Disorder Among Active Duty Military Personnel. JOURNAL OF TRAUMATIC STRESS. doi:10.1002/jts.22416
Questions for Discussion:
- What are the pros and cons of implementing a treatment that specifically targets guilt in the context of PTSD?
- Should clinicians alter their treatment plan on the basis of whether guilt is perceived as justified (versus unjustified) by the service member?
- How might military service impact the experience or reporting of guilt among treatment seekers?
About the Authors:
Carmen McLean, PhD,
is a clinical psychologist at the Dissemination and Training Division of the National Center for PTSD at the Palo Alto VA and a Clinical Associate Professor (Affiliate) in the Department of Psychiatry and Behavioral Sciences at Stanford University. Her research examines ways to increase the reach of exposure therapies for PTSD by addressing therapist and clinic-level implementation barriers and testing eHealth and mHealth interventions, with the overall goal of helping more individuals with PTSD benefit from evidence-based treatment.
Lily Brown, PhD,
is an Assistant Professor in the Department of Psychiatry at the University of Pennsylvania. Her research focuses on the intersection of anxiety-related disorders, including PTSD, and suicide risk. Specifically, she explores how changes in anxiety-related distress influence changes in suicide risk over time, as well as strategies to prevent suicide among individuals with anxiety.