Cognitive Therapy in the Treatment of Posttraumatic Stress Disorder: Targeting Trauma-Related Guilt
Posttraumatic stress disorder is categorized in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders on Axis 1 as a subtype of anxiety disorders. PTSD develops after a person experiences or witnesses a traumatic event. Patients with the disorder suffer from extreme emotional distress caused by recollections, dreams, and exposure to memory provoking stimuli. In some cases, individuals suffer PTSD after an event in which they were solely the victims. For example, a person, alone in his or her car and stopped at a red light, who is hit by a drunk driver and is hospitalized with serious injuries, may develop PTSD. In cases such as these, victims develop PTSD due entirely to the trauma itself, and cognitive-behavioral therapies are introduced in order to help them learn to cope with the memories. However, many cases involve scenarios in which an individual has somewhat contributed to the traumatic event and therefore develops PTSD with moral injury as its leading cause. Combat veterans, who suffer “survivor’s guilt” or who unintentionally killed innocent women and children, are primary examples of those who suffer from PTSD due to moral injury (Kubany, Haynes, Abueg, Marke, Brennan, & Stahura, 1995).
The DSM-IV-TR characterizes fear, horror, and helplessness as the primary stressors for Posttraumatic stress disorder. However, while these emotions are directly linked to the physical aspects of traumatic experiences, such as threat of physical injury and death, they do not incorporate the psychosocial dimensions of traumatic experiences. It has been argued that shame should be integrated as a criterion A stressor (Budden, 2009). Secondary emotions such as guilt and shame come as a result of more extensive cognitive processes and can cause of PTSD (Grey, Holmes & Brewin, 2001). In fact, there is a positive correlation between beliefs about the violation of personal values and the severity of PTSD symptoms (Kubany et al., 1995). Shame, by definition, is “a painful emotion characterized by a strong sense of guilt, embarrassment, unworthiness, or disgrace, caused by the consciousness of wrong or foolish behavior” (http://www.thefreedictionary.com/shame). Guilt is a strongly related emotion, defined as “remorseful awareness of having done something wrong” (http://www.thefreedictionary.com/guilt). Closely intertwined, guilt focuses on one’s actions while shame focuses on one’s moral integrity and perception of one’s actions. It could be said that while guilt inspires the “I should have, I wish I had” thoughts in hindsight bias, shame stirs one to feel badly about who he or she is, inspiring thoughts such as “I am a terrible person, I hate myself.” Recently, research has been conducted in order to evaluate whether different treatments should be used to target these specific cognitive process, such as shame and guilt. Cognitive-behavioral therapy is the most common treatment for individuals who suffer from PTSD. There are four basic components of cognitive-behavioral treatment: psychoeducation, exposure, cognitive restructuring, and anxiety management. The first, psychoeducation, works to help patients justify and legitimize their symptoms as typical of a trauma reaction. This will help them understand why they are experiencing fearful and negative emotions and how treatment will help them. The second component works to expose the patient to the trauma-related stimuli through a series of imaginal and in vivo techniques (Harvey, Bryant & Tarrier, 2003). By reliving the experience in a controlled environment, the patient is able to reduce his or her anxiety systematically and learn to control his or her response to the traumatic memories with habituation; this is the imaginal factor. The in vivo factor forces the patient to face the fear-invoking stimuli in real-life situations, helping him or her...
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