Editor’s note: Sonya Norman is a developer of Trauma Informed Guilt Reduction Therapy (TrIGR). She has disclosed the publication of the treatment manual as a conflict of interest.
Research over the past decade has shown posttraumatic guilt (negative affect and cognitions regarding one’s behavior—i.e., “I did something bad”) and shame (negative affect and cognitions regarding the entire self—i.e., “I am bad”) are highly prevalent among trauma survivors, and they play a role in the severity of posttraumatic mental health problems. More than 80% of trauma survivors with probable PTSD report experiencing posttraumatic guilt in their lifetime, with 34% reporting experiencing guilt in the past month (Miller et al, 2012). Among U.S. veterans, a representative study found 54% endorse guilt in their lifetime, 41% endorse current guilt, and 35% are moderately or extremely bothered by guilt (Miller et al., 2012).
Guilt and shame are common across trauma types. For example, survivors of partner violence may feel guilty for having stayed in the relationship or exposing children to abuse. A driver during a motor vehicle accident may feel guilty because others were hurt or died. Assault survivors may feel guilty because they believe they did something to trigger or failed to prevent the assault. Due to growing recognition of the high prevalence of guilt and shame among those with trauma exposure and posttraumatic stress disorder (PTSD), the latest version of the Diagnostic and Statistical
Manual (DSM5; American Psychiatric Association, 2013) included guilt and shame as a symptom of PTSD for the first time.
People who experience guilt and shame following trauma are likely to have more severe mental health problems, such as PTSD (Gaudet, Sowers, Nugent, & Boriskin, 2016; Pugh, Taylor, & Berry, 2015; Saraiya & Lopez-Castro, 2016), depression (Browne, Trim, Myers, & Norman, 2015; Marx et al., 2010), and substance use (Wilkins, Myers, Goldsmith, Buzzella, & Norman, 2013), than those without guilt and shame. Guilt and shame are also associated with greater likelihood of experiencing suicidal ideation and suicide attempts (Bryan, Morrow, Etienne, & Ray-Sannerud, 2013; Tripp & McDevitt-Murphy, 2017), and having more severe impairment in social and occupational functioning (Norman et al., 2018).
Guilt and shame are also core features of moral injury (Frankfurt & Frazier, 2016; Jinkerson, 2016; Litz et al., 2009), which is highly prevalent among military service members and veterans who served in combat (Wisco et al., 2017). This is not surprising given that combat and war often call for behaviors that may not be in line with one’s values outside of the context of war, such as witnessing or participating in atrocities or killing civilians. Another common source of guilt that can also be a cause of moral injury is one’s reaction during a traumatic event. For example, veteran clients have shared that feeling nothing or feeling pleasure in the moment they killed someone can result in feeling guilt and shame.
Given the many associated mental health and functional problems, posttraumatic guilt and shame are important targets for intervention. PTSD is one of the most common disorders that occurs in those experiencing posttraumatic guilt and shame. Studies that have examined whether evidence-based treatments for PTSD such as prolonged exposure therapy and cognitive processing therapy effectively reduce trauma-related guilt have had mixed results. Several studies have found these treatments to be effective in reducing guilt (e.g., Capone et al., submitted; Clifton, Feeny, Zoellner, 2017; Resick et al., 2002). On the other hand, some studies have found guilt to be a likely residual symptom, even among those who have otherwise benefited from treatment (e.g., Larsen et al., 2019; Owen, Chard, Cox, 2008). One study found guilt severity at baseline to predict less PTSD symptom change throughout treatment (Øktedalen, Hoffart, & Langkaas 2015). A likely reason for these discrepant findings is variability in what traumas were targeted in treatment (as many people with PTSD have experienced multiple traumas), and the extent to which guilt was addressed in therapy. In order to better understand the role of PTSD treatments in reducing guilt, future studies should examine not just outcome, but if and how guilt was addressed in treatment.
Posttraumatic guilt and shame are also associated with increased severity of depression and substance use disorder, although treatments for these typically do not include processing guilt and shame that are specific to trauma. For example, depression treatment may address a general pervasive feeling of guilt that is common to depression. Substance use treatment may address guilt and shame from not being able to stop using substances or from hurting loved ones due to addiction. However, neither of these involve attending to guilt and shame related to trauma.
In summary, guilt and shame are related to multiple forms of posttraumatic psychopathology and posttraumatic distress not limited to PTSD. Furthermore, clinicians are seeking more strategies to address guilt related to trauma in psychotherapy (Becker, Zayfert, & Anderson, 2004; Drescher et al., 2011). Given these factors, additional intervention strategies to reduce guilt and shame are warranted. We (Carolyn Allard, Kendall Browne, Christy Capone, Brittany Davis, and I) developed Trauma Informed Guilt Reduction Therapy (TrIGR; Norman et al., 2019) to add to the available treatment options to address guilt and shame related to trauma and moral injury.
TrIGR is a brief manualized intervention that consists of three modules that can each be delivered in two 60- to 90-minute sessions (for a total of six sessions): 1) psychoeducation regarding the role of guilt and shame in posttraumatic distress and common types of trauma-related guilt and shame; 2) appraisal of trauma-related guilt and shame cognitions, and helping the client recall the fuller, more accurate context of what occurred during the time of the trauma; and 3) helping clients identify important values and develop a plan that allows the client to live in line with these values going forward.
Kubany and colleagues identified four common cognitions among people who experience trauma-related guilt and suggested that appraising such beliefs would lead to reductions in guilt and related distress (Kubany, 1994; Kubany & Ralston, 1998). These cognitive errors are hindsight-bias (believing that the outcome was known at the time of the trauma), lack of justification (believing there was no or little justification for the course of action one chose to take), responsibility (believing one was solely or mostly responsible for the traumatic event), and wrongdoing (believing one purposely did something that was wrong or violated important values). TrIGR utilizes cognitive strategies developed by Kubany and colleagues (e.g., Kubany et al., 1995; Kubany & Watson, 2003) as well as additional approaches to help clients “debrief” guilt and shame beliefs and develop a broader and often more accurate understanding of their role in the outcome of the trauma.
Going through the debrief can help clients appreciate that they may have done the best they could or that there was no possible good outcome during their trauma, but we have found that many clients are still wary of letting go of guilt because it serves the function of helping them express important values. Our clients have express beliefs, such as, “If I didn’t feel guilty about what I did, what would stop me from doing it again?” or “Then I would really be a bad person,” or “How else would I honor the memory of the person I lost?” For this reason, the latter sessions of TrIGR focus on helping clients recognize the function of their guilt in regard to their values and take steps to identify and live in line with personal values in a meaningful, positive and more functional way.
Research to understand the effectiveness of TriGR is underway. In a pilot study with veterans who had served in Iraq and Afghanistan (Norman et al, 2014), we saw significant decreases in guilt cognitions and guilt severity from pre- to post-treatment. We also saw clinically meaningful decreases in PTSD and depression symptom severity. Change in guilt and change in PTSD symptom severity were significantly correlated.
We are currently conducting the first randomized controlled trial of TrIGR. This is a two-site study through the San Diego VA/University of California San Diego School of Medicine and the Providence VA/Brown University. Our goal is to compare TrIGR to a supportive present-centered psychotherapy and examine change in posttraumatic guilt and shame, as well change in PTSD and depression symptoms, suicidal ideation and behavior, and functioning.
We look forward to learning more about how to effectively reduce guilt and shame in the coming years given its role in mental health problems and distress among trauma survivors.
About the Author:
Sonya Norman, PhD, is the PTSD Consultation Program Director at the U.S. National Center for PTSD and a Professor in the Psychiatry Department at the University of California, San Diego School of Medicine.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5®)
(5th Ed.). Arlington, VA: American Psychiatric Publishing.
Becker, C.B., C. Zayfert, and E. Anderson, A survey of psychologists’ attitudes towards and utilization of exposure therapy for PTSD.
Behaviour Research and Therapy, 2004. 42(3): p. 277-292.
Browne, K. C., Trim, R. S., Myers, U. S., & Norman, S. B. (2015). Trauma-related guilt: Conceptual development and relationship with posttraumatic stress and depressive symptoms. Journal of Traumatic Stress
(2), 134–141. https://doi.org/10.1002/jts.21999
Bryan, C. J., Morrow, C. E., Etienne, N., & Ray-Sannerud, B. (2013). Guilt, shame, and suicidal ideation in a military outpatient clinical sample. Depression and Anxiety
(1), 55–60. https://doi.org/10.1002/da.22002
Bryan, C. J., Ray-Sannerud, B., Morrow, C. E., & Etienne, N. (2013). Guilt is more strongly associated with suicidal ideation among military personnel with direct combat exposure. Journal of Affective Disorders
(1), 37–41. https://doi.org/10.1016/j.jad.2012.11.044
Capone, C., Tripp, J. C., Trim, R. S., Davis, B. C., Haller, M., & Norman, S. B. (submitted). Comparing the Effects of Exposure Treatment versus Coping Skills Treatment on Trauma-Related Guilt in Veterans with Co-Occurring PTSD and Alcohol Use Disorders.
Drescher, K.D., et al., An Exploration of the Viability and Usefulness of the Construct of Moral Injury in War Veterans.
Traumatology, 2011. 17(1): p. 8-13.
Frankfurt, S., & Frazier, P. (2016). A review of research on moral injury in combat veterans. Military Psychology
(5), 318–330. https://doi.org/10.1037/mil0000132
Gaudet, C. M., Sowers, K. M., Nugent, W. R., & Boriskin, J. A. (2016). A review of PTSD and shame in military veterans. Journal of Human Behavior in the Social Environment
(1), 56–68. https://doi.org/10.1080/10911359.2015.1059168
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2016). Acceptance and commitment therapy: The process and practice of mindful change
(2nd Ed.). New York, NY: The Guilford Press.
Jinkerson, J. D. (2016). Defining and assessing moral injury: A syndrome perspective. Traumatology
(2), 122–130. http://dx.doi.org/10.1037/trm0000069
Kubany, E. S. (1994). A cognitive model of guilt typology in combat-related PTSD. Journal of Traumatic Stress
Kubany, E.S., et al., Initial examination of a multidimensional model of trauma-related guilt: Applications to combat veterans and battered women.
Journal of Psychopathology and Behavioral Assessment, 1995. 17(4): p. 353-376.
Kubany, E. S., & Ralston, T. C. (1998). Cognitive therapy for trauma-related guilt. In V. M. Follette & J. I. Rusek (Eds.), Cognitive-behavioral therapies for trauma
(pp. 124–161). New York, NY: The Guilford Press.
Larsen, S. E., Fleming, C. J. E., & Resick, P. A. (2018). Residual symptoms following empirically supported treatment for PTSD. Psychological Trauma: Theory, Research, Practice, and Policy
Lewis, H. B. (1971). Shame and guilt in neurosis. Psychoanalytic Review
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
(8), 695–706. https://doi.org/10.1016/j.cpr.2009.07.003
Marx, B. P., Foley, K. M., Feinstein, B. A., Wolf, E. J., Kaloupek, D. G., & Keane, T. M. (2010). Combat-related guilt mediates the relations between exposure to combat-related abusive violence and psychiatric diagnoses. Depression and Anxiety
(3), 287–293. https://doi.org/10.1002/da.20659
Miller, M.W., et al., (2012). The Prevalence and Latent Structure of Proposed DSM-5 Posttraumatic Stress Disorder Symptoms in US National and Veteran Samples.
Øktedalen, T., Hoffart, A., & Langkaas, T.F. (2015) Trauma-related shame and guilt as time-varying predictors of posttraumatic stress disorder symptoms during imagery exposure and imagery rescripting—A randomized controlled trial, Psychotherapy Research, 25:5, 518-532, DOI: 10.1080/10503307.2014.917217
Norman, S. B., Allard, C.B., Browne, K. C., Capone, C., Davis, B. C., & Kubany, E. S. (2019). Trauma Informed Guilt Reduction Therapy: Treating Guilt and Shame Resulting from Trauma and Moral Injury. San Diego, CA: Academic Press as an imprint of Elsevier.
Norman, S. B., Haller, M., Kim, H. M., Allard, C. B., Porter, K. E., Stein, M. B., … Rauch, S. (2018). Trauma related guilt cognitions partially mediate the relationship between PTSD symptom severity and functioning among returning combat veterans. Journal of Psychiatric Research
, 56–62. https://doi.org/10.1016/j.jpsychires.2018.02.003
Norman, S. B., Wilkins, K. C., Myers, U. S., & Allard, C. B. (2014). Trauma informed guilt reduction therapy with combat veterans. Cognitive and Behavioral Practice
(1), 78–88. https://doi.org/10.1016/j.cbpra.2013.08.001
Øktedalen, T., Hagtvet, K. A., Hoffart, A., Langkaas, T. F., & Smucker, M. (2014). The trauma related shame inventory: Measuring trauma-related shame among patients with PTSD. Journal of Psychopathology and Behavioral Assessment
(4), 600–615. https://doi.org/10.1007/s10862-014-9422-5
Orsillo, S. M., & Batten, S. V. (2005). Acceptance and commitment therapy in the treatment of posttraumatic stress disorder. Behavior Modification
Owens, G. P., Chard, K. M., & Ann Cox, T. (2008). The relationship between maladaptive cognitions, anger expression, and posttraumatic stress disorder among veterans in residential treatment. Journal of Aggression, Maltreatment & Trauma
(4), 439–452. https://doi.org/10.1080/10926770802473908
Pugh, L. R., Taylor, P. J., & Berry, K. (2015). The role of guilt in the development of post-traumatic stress disorder: A systematic review. Journal of Affective Disorders
(Supplement C), 138–150. https://doi.org/10.1016/j.jad.2015.04.026
Resick, P. A., Nishith, P., Weaver, T. L., Astin, M. C., & Feuer, C. A. (2002). A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. Journal of Consulting and Clinical Psychology
(4), 867-879. http://dx.doi.org/10.1037/0022-006X.70.4.867
Saraiya, T., & Lopez-Castro, T. (2016). Ashamed and afraid: A scoping review of the role of shame in post-traumatic stress disorder (PTSD). Journal of Clinical Medicine
(11), E94. https://doi.org/10.3390/jcm5110094
Tripp, J. C., & McDevitt-Murphy, M. E. (2017). Trauma-related guilt mediates the relationship between posttraumatic stress disorder and suicidal ideation in OEF/OIF/OND veterans. Suicide and Life-Threatening Behavior
(1), 78–85. https://doi.org/10.1111/sltb.12266
Wilkins, K. C., Myers, U. S., Goldsmith, A. A., Buzzella, B., & Norman, S. B. (2013, April). High-risk behaviors in Iraq and Afghanistan veterans: The role of trauma-related guilt. Symposium presented at the Anxiety and Depression Association of America Annual Conference, La Jolla, CA.
Wisco, B. E., Marx, B. P., May, C. L., Martini, B., Krystal, J. H., Southwick, S. M., & Peitrzak, R. H. (2017). Moral injury in U.S. combat veterans: Results from the national health and resilience in veterans study. Deprssion and Anxiety
. doi: 10.1002/da.22614. [Epub ahead of print]