Jennifer Schuster Wachen

Trauma‐related guilt and shame are common following traumatic or potentially morally injurious events. Improving guilt and shame is often a goal of treatment, and providers express a desire for more strategies to manage guilt and shame for individuals with posttraumatic stress disorder (PTSD) and moral injury. Evidence‐based psychotherapies for PTSD, such as prolonged exposure, cognitive processing therapy, and eye movement desensitization and reprocessing therapy, have been found to improve trauma‐related guilt and shame among individuals with PTSD and/or moral injury. This paper provides an overview of the assessment of trauma‐related guilt and shame, as well as therapist considerations for treatment, and explores each treatment, its evidence, and its approach to treating guilt and shame. Applied techniques and strategies to maximize effectiveness in addressing guilt and shame are provided for each of these treatments. Future research is needed to inform clinical decision‐making, the treatment of residual shame and guilt, and the assessment of trauma‐related shame and guilt throughout treatment.

This study explored the association between changes in pain and related health outcomes and posttraumatic stress disorder (PTSD) symptoms following cognitive processing therapy (CPT) in an active duty military sample. Based on the mutual maintenance model, we hypothesized that PTSD symptom reductions would be associated with improvements in pain and health symptoms following CPT. This secondary, intent‐to‐treat analysis included data from a parent trial of 127 active duty U.S. Army soldiers diagnosed with PTSD who were receiving variable‐length CPT. We used mixed‐effect regression models with repeated measures to examine whether treatment responders (i.e., individuals with a reduction of 11 points or more on the PCL‐5) demonstrated improvements in pain and health outcomes posttreatment. Models included fixed effects of visit (baseline and 1‐month follow‐up), clinically significant PTSD improvement classification (present or absent), and the respective interaction. There were significant interactions on pain interference, F (1, 75.92) = 6.32, p = .014; perceived life control, F (1, 95.59) = 5.17, p = .025; affective distress, F (1, 83.15) = 9.77 p = .002; mental health, F (1, 96.27) = 20.75, p < .001; physical health, F (1, 84.97) = 3.98, p = .049; and somatic symptoms, F (1, 80.64) = 6.08, p = .016. These interactions revealed that participants with clinically significant PTSD improvement following CPT also demonstrated certain better pain and health outcomes compared to nonresponders. Service members with pain and health issues in addition to PTSD who respond to CPT may also report improvements in these issues posttreatment, increasing the value of connecting them to treatment.

In posttraumatic stress disorder (PTSD), the assumption of the equipotentiality of traumas ignores potentially unique contexts and consequences of different traumas. Accordingly, Stein et al. (2012) developed a reliable typing scheme in which assessors categorized descriptions of traumatic events into six "types": life threat to self (LTS), life threat to other, aftermath of violence (AV), traumatic loss, moral injury by self (MIS), and moral injury by other (MIO). We extended this research by validating the typing scheme using participant endorsements of type, rather than assesor-based types. We examined the concordance of participant and assesor types, frequency, and validity of participant-based trauma types by examining associations with baseline mental and behavioral health problems. Interviewers enrolled military personnel and veterans (N = 1,443) in clinical trials of PTSD and helped them select the most currently distressing Criterion-A trauma. Participants and, archivally, assessors typed the distressing aspect(s) of this experience. AV was the most frequently participant-endorsed type, but LTS was the most frequently rated worst part of an event. Although participants endorsed MIS and MIO the least frequently, these were associated with worse mental and behavioral health problems. The agreement between participants and assessors regarding the worst part of the event was poor. Because of discrepancies between participant and assessor typologies, clinical researchers should use participants' ratings, and these should trump assessor judgment. Differences in pretreatment behavioral and mental health problems across some participant-endorsed trauma types partially support the validity of the participant ratings. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Between 44% and 87% of active duty service members and veterans who deployed following the September 11, 2001, terrorist attacks know someone who was killed or seriously injured in combat. Considering the high frequency and known impact of traumatic loss, it is important to understand if and how traumatic loss may impede posttraumatic stress disorder (PTSD) treatment progress in military personnel. Additionally, experiencing a traumatic loss elevates the risk of developing prolonged grief disorder (PGD), which is associated with higher levels of PTSD symptoms, more functional impairment, and more lifetime suicide attempts among military personnel. Given what is known about the association between PGD and PTSD in treatment‐seeking service members and veterans, it is also important to understand whether grief‐related symptom severity negatively impacts PTSD treatment response. The current study examined associations among traumatic loss, complicated grief, depressive symptoms, and PTSD treatment response among military personnel (N = 127) who participated in variable‐length cognitive processing therapy (CPT). There was no direct, F(2, 125) = 0.77, p = .465, or indirect, β = .02, p = .677, association between a traumatic loss index event and PTSD treatment response compared with other trauma types. Prior assessments of depressive symptom severity were directly related to PTSD at later assessments across two models, ps < .001–p = .021 Participants with a traumatic loss index trauma demonstrated significant reductions in complicated grief, depressive symptoms, and PTSD following CPT, ps < .001, ds = −0.61–−0.83. Implications, study limitations, and suggestions for future research are presented.

Cognitive processing therapy (CPT) is a first‐line treatment for posttraumatic stress disorder (PTSD). The primary goals of CPT are to identify and challenge dysfunctional cognitions resulting from the trauma to promote a more balanced set of beliefs and reduce manufactured emotions; encouraging expression of natural emotions further promotes symptom improvement. Between‐session assignments (homework) are an integral part of learning and practicing the skills developed during CPT, and these assignments are theorized to reinforce the proposed mechanisms of symptom change. This article begins with a brief description of the theoretical foundations of CPT and an overview of the session content of the CPT protocol, followed by a case study illustrating the use of CPT with the written account (CPT + A) with a survivor of childhood sexual assault. Although the client demonstrated some avoidance, her successful completion of practice assignments throughout treatment allowed her to identify and examine thoughts contributing to feelings of guilt and self‐blame as well as negative beliefs about the world. She was able to reduce her assimilated and overaccommodated stuck points to form a more balanced view of the trauma, and also process her natural emotions, resulting in a significant reduction of PTSD symptoms. The role of homework at each session and how the assignments addressed the proposed mechanisms of change in CPT are discussed, and recommendations to increase clients’ engagement in practice assignments in CPT are provided.