Military Operational Medicine (JPC-5)
Healing from Traumatic Events by Targeting Feelings of Guilt
Posted May 13, 2022
Sonya Norman, Ph.D., National Center for PTSD and University of California San Diego
Christy Capone, Ph.D., Brown University Medical School and Providence VA Medical Center
During warfare, U.S. active-duty Service Members may experience traumatic events and have to make quick decisions in unclear situations, which may lead to feelings of guilt and shame. These feelings can perpetuate other mental health difficulties sometimes experienced by warfighters, including posttraumatic stress disorder (PTSD), depression, suicide ideation, and substance use. Guilt is one of the most likely PTSD-associated symptoms to remain after effective treatment of the disorder.1 The commonality of persistent guilt underlying several trauma-related mental health diagnoses indicates a need for treatments specifically targeting guilt as a method to more effectively address trauma-related symptoms. By targeting guilt associated with traumatic events, Service Members and Veterans could receive more effective treatment for trauma-related symptoms to better move forward with their lives.
Dr. Norman and Dr. Capone, from University of California San Diego and Brown University respectively, have been investigating the effectiveness of Trauma-Informed Guilt Reduction (TrIGR) therapy with Psychological Health and Traumatic Brain Injury Research Program funding from a Military Operational Medicine Research Program Fiscal Year 2014 Psychological Health Research Award - Partnering Principal Investigator Option. Together with their colleagues, the pair developed TrIGR through their experience working with combat Veterans, during which they observed the suffering experienced by individuals ridden with guilt and shame associated with traumatic events. These emotions often impeded mental health improvements and the ability of Veterans to move forward with their lives.
The TrIGR intervention addresses the guilt, shame, and moral injury that underlie several trauma-related disorders. The intervention was assessed in a first-of-its-kind randomized controlled trial in the U.S. Department of Veterans Affairs (VA) Medical Centers at San Diego, California and Providence, Rhode Island. A total of 145 Veterans deployed in Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn with measurable guilt were recruited to assess the effectiveness of TrIGR compared to supportive care therapy (SCT). SCT includes characteristics of traditional therapies without the additional principles included in TrIGR.
TrIGR consists of six 90-minute sessions broken into four modules. Module one educates participants about guilt, shame, moral injury and the non-adaptive guilt and shame (NAGS) model that forms the basis of the intervention. The NAGS model facilitates redirection of feelings of guilt to change behaviors that are consistent with personal values.2 In module two, participants identify thoughts that play a role in post-traumatic guilt and participate in discussions about the role of guilt in their lives and what it would be like to have decreased guilt and shame. The discussions help to identify values that were debased during the traumatic event and facilitates modules three and four, in which participants work toward positive ways to direct their values to personal growth.
Several outcomes were assessed with the primary outcome being changes in guilt. There was a greater decrease in guilt in Veterans receiving TrIGR compared to those receiving SCT. Secondary outcomes assessed were changes in shame and improvements in quality of life; feelings of shame improved in both groups but there was no change in quality of life.3 Last, exploratory outcomes were also assessed, including PTSD and depression symptoms and severity. Figure 1 showed that similar to guilt, PTSD and depression symptoms decreased more in participants receiving TrIGR compared to those receiving SCT.3 Half of those who received TriGR lost their PTSD diagnosis while fewer than 20% did in SCT. Overall, the findings suggest that targeting guilt may be an effective means to reduce trauma-related symptoms. Additionally, Drs. Norman and Capone, together with other colleagues, are now conducting a study to see if TriGR can help with the guilt and shame that some people experience from events related to the COVID-19 pandemic.
The investigators are optimistic that their study will encourage the use of TrIGR in military populations and others suffering with trauma-related guilt. They, with their team of therapists, have been honored to work with Veterans as part of their path to healing and recovery and hope to continue working with Veteran populations in the future. The team’s ultimate goal is to understand if TrIGR works for all types of trauma-related guilt and to increase the overall utilization if indicated by the data. This will be achieved by completing trials comparing TrIGR to other treatments for PTSD and evaluation of effectiveness in Veterans with any type of trauma and from other combat eras. If successful, TrIGR could be used to help Service Members and Veterans with high guilt, shame, or moral injury recover from trauma.
Capone C, Norman SB, Moira H, et al. 2021. Trauma informed guilt reduction (TrIGR) therapy for guilt, shame, and moral injury resulting from trauma: Rationale, design, and methodology of a two-site randomized controlled trial. Contemporary Clinical Trials 101 101:106251. doi: 10.1016/j.cct.2020.106251
McLean CP, Back SE Capone C, et al. 2021. The impact of COVID-19 on psychotherapy participation with posttraumatic stress disorder enrolled in treatment. Journal of Traumatic Stress 35(1). doi: 10.1002/jts.22718
Norman SB, Capone C, Panza KE, et al. 2022. A clinical trial comparing trauma-informed guilt reduction therapy (TrIGR), a brief intervention for trauma-related guilt, to supportive care therapy. Depression and Anxiety 39(4):262-273. doi: 10.1002/da.23244
1S.E. Larsen, C.J.E. Fleming, P.A. Resick, Residual symptoms following empirically supported treatment for PTSD, Psychol. Trauma Theory Res. Pract. Policy 11 (2) (2019) 207–215, https://doi.org/10.1037/tra0000384.
2Norman SB and Haller M. 2020. Guest perspective: Guilt, shame, and moral injury from events during the COVID-19 pandemic. Deployment Psychology Blog. https://deploymentpsych.org/blog/guest-perspective-guilt-shame-and-moral-injury-events-during-covid-19-pandemic.
3Norman SB, Capone C, Panza KE, et al. 2022. A clinical trial comparing trauma-informed guilt reduction therapy (TrIGR), a brief intervention for trauma-related guilt, to supportive care therapy. Depression and Anxiety 39(4):262-273. doi: 10.1002/da.23244
Last updated Thursday, May 26, 2022