A cognitive behavioural therapy (CBT) approach for working with strong feelings of guilt after traumatic events

Abstract

This article outlines a cognitive behavioural therapy (CBT) approach to treating feelings of guilt and aims to be a practical ‘how to’ guide for therapists. The therapeutic techniques were developed in the context of working with clients with a diagnosis of post-traumatic stress disorder (PTSD); however, the ideas can also be used when working with clients who do not meet a diagnosis of PTSD but have experienced trauma or adversity and feel guilty. The techniques in this article are therefore widely applicable: to veterans, refugees, survivors of abuse, the bereaved, and healthcare professionals affected by COVID-19, amongst others. We consider how to assess and formulate feelings of guilt and suggest multiple cognitive and imagery strategies which can be used to reduce feelings of guilt. When working with clients with a diagnosis of PTSD, it is important to establish whether the guilt was first experienced during the traumatic event (peri-traumatically) or after the traumatic event (post-traumatically). If the guilt is peri-traumatic, following cognitive work, this new information may then need to be integrated into the traumatic memory during reliving. Key learning aims (1) To understand why feelings of guilt may arise following experiences of trauma or adversity. (2) To be able to assess and formulate feelings of guilt. (3) To be able to choose an appropriate cognitive technique, based on the reason for the feeling of guilt/responsibility, and work through this with a client. (4) To be able to use imagery techniques to support cognitive interventions with feelings of guilt.

Application of an Adapted ACT Group Intervention in Survivors of Childhood Cancer: The Survivor-Enhanced Take-A-Breath Protocol

“…Specific findings also supported the physically engaging strategies were effective in increasing certain physical abilities of these survivors, such as mobility and endurance (Gilliam, et al, 2011) and overall quality of life (Li, et al, 2013). These studies demonstrated that a cognitive-behavioral framework can be effective at improving health promoting behaviors (Cox, et al, 2005;Li, et al, 2013;Mays, et al, 2011;Young, et al, 2021). To improve on these in the future, researchers suggest that studies create more regular contacts (Gilliam, et al, 2011;Li, et al, 2013), include a greater degree of intervention (Mays, et al, 2011), and consideration for age and gender (Cox, et al, 2005).…”

“…The findings of this study present various implications for clinical practice concerning survivors of childhood cancer, especially with regard to their navigating late effects of their disease and treatment. This study was developed to address the many needs of this population, including general introduction and access to mental healthcare (Oeffinger, et al, 2010), interpersonal skills and unlearning of learned social isolation (Chevignard, et al, 2017), radical acceptance of traumatic events and experiences (Perloff, et al, 2019), and the provision of workable coping skills for distress tolerance (Young, et al, 2021). This study's findings suggest that the Survivor Enhanced Take-A-Breath Protocol may be a feasible and functional support strategy for survivors of childhood cancer.…”

“…ACT strategies have been suggested as one of the preferred methods for addressing survivorship guilt in survivors of cancer (Perloff, et al, 2019). Since these intervention strategies have been demonstrated effective throughout the literature with survivors of childhood cancer (Michel, et al, 2020;Perloff, et al, 2019;Young et al, 2021), it is vital that adolescent and young adults'…”

“…In order to address such late effects, there are some interventions available for specific late effects (Arch, et al, 2019;Brier, et al, 2015). The vast majority of the psychological interventions for this population exist to treat anxiety and related symptoms (Arch, et al, 2019;Young, et al, 2021). There are also intervention strategies expressly detailed for post-traumatic stress symptoms (Arpawong, et al, 2013).…”

Exploring the impact on primary care mental health practitioners of the death of a patient by suicide: An IPA study

“…Helping mitigate practitioners' sense of guilt could be informed by Kubany's model for the understanding and treatment of trauma related guilt (Kubany & Manke, 1995 ; Young et al, 2021 ). This highlights four potential cognitive biases: hindsight‐bias (i.e., presuming that current knowledge of the outcome was known at the time of the event) ‘Now I know what happened, if I'd had that knowledge when I went back, you would do something different because you know the outcome’; responsibility (i.e., taking on all or most of the responsibility for the event) ‘this was my case and he was my patient and it was just me and I thought this is…I'm responsible for this young lad’; justification (i.e., believing there was no justification for choices taken at the time and ignoring the conditions under which you took those choices) ‘….judged and criticised for the decisions I made’; and wrongdoing (i.e., the belief that you have violated personal values) ‘dread feeling that you've done something wrong’.…”