Effectiveness of treatments for symptoms of post-trauma related guilt, shame and anger in military and civilian populations: a systematic review

Abstract

IntroductionIndividuals who have been exposed to a traumatic event can develop profound feelings of guilt, shame and anger. Yet, studies of treatments for post-traumatic stress disorder (PTSD) have largely investigated changes in PTSD symptoms relating to a sense of ongoing fear or threat and the effectiveness of such treatments for post-trauma related guilt, shame or anger symptom reduction is comparatively not well understood.MethodsThis review systematically examined the effectiveness of existing treatment approaches for three symptoms associated with exposure to traumatic events: guilt, shame and anger. Studies included had to be published after 2010 with a sample size of n=50 or greater to ensure stable treatment outcome estimates.Results15 studies were included, consisting of both civilian and (ex-) military population samples exposed to a wide range of traumatic events (eg, combat-related, sexual abuse). Findings indicated a moderate strength of evidence that both cognitive-based and exposure-based treatments are similarly effective in reducing symptoms. Cognitive-based treatments were found to effectively reduce post-trauma related guilt and anger, while exposure-based treatments appeared effective for post-trauma related guilt, shame and anger.ConclusionsThe findings suggest the importance of confronting and discussing the traumatic event during therapy, rather than using less directive treatments (eg, supportive counselling).Nonetheless, while these results are promising, firm conclusions regarding the comparative effectiveness and long-term impact of these treatments could not be drawn due to insufficient evidence. Further empirical research is needed to examine populations exposed to traumatic events and investigate which treatment approaches (or combination thereof) are more effective in the long-term.

Professionals' perspectives on relevant approaches to psychological care in moral injury: A qualitative study

“…Results from other studies indicate the need to modify existing manualised treatments or combine alternative therapeutic tools/techniques to better address symptoms of MI. More specifically, recent studies and reviews also suggest that alternative approaches, such as AD, ACT, CFT, pastoral care interventions or spiritual/religious treatments may be beneficial by covering many aspects of patients' lives (Barnes et al, 2019; Koenig & Al Zaben, 2021; Serfioti et al, 2022; Williamson et al, 2021a). Notably, what was believed to be the key for effective clinical treatment or psychological care with long‐term benefits in the present study was the effort made by the professional to adjust therapeutic techniques to the patient's unique needs and way of life.…”

“…Although, it is argued that evidence‐based PTSD treatments could be sufficient (Held et al, 2018), some disagree (Litz et al, 2016; Phelps et al, 2022). For example, previous research suggested that prolonged exposure (PE) could potentially be harmful in cases of MI and exacerbate patient reactions of shame, disgust and guilt (Maguen & Burkman, 2013), however, in a recent systematic review cognitive‐based treatments were found to effectively reduce symptoms of guilt and anger, while exposure‐based treatments appeared effective for symptoms of guilt, shame and anger (Serfioti et al, 2022). Nonetheless, for example, in the United Kingdom (UK), clinicians have reported using a combination of several validated treatment approaches, such as compassion‐focused therapy, elements of schema therapy or trauma‐focused cognitive behavioral therapy, to treat patients with MI (Williamson et al, 2019; Williamson, Greenberg, Murphy, 2020; Williamson et al, 2021a).…”

Restore and Rebuild (R&R): a protocol for a phase 2, randomised control trial to compare R&R as a treatment for moral injury-related mental health difficulties in UK military veterans to treatment as usual

“…Sessions are 60 min in length and occur weekly, however, a 4-week break in sessions takes place between sessions 19 and 20 (the final session). Following a review of existing treatments and codevelopment with experts and veterans with moral injury, 41 R&R was designed to include moral injury psychoeducation; discussion of the PMIE(s); exploration of postevent changes in beliefs and thought processes; support to adaptively rewrite or update these; and an examination of core values and goals for the future. R&R includes in-session discussions with a therapist, as well as written exercises, thought records and worksheets, completed both inside and outside of sessions by veteran patients.…”

Changes in trauma appraisal during brief internet-based exposure and cognitive restructuring treatment for Arabic-speaking people with PTSD

“…Some empirical studies further suggest a reduction in non-fear appraisals such as guilt and shame in both treatment types (e.g. Serfioti et al, 2022 ). To date, studies investigating the impact of exposure and cognitive treatments on trauma appraisal in civilian samples have been small and mainly conducted in the United States or European countries.…”

“…Changes in maladaptive posttraumatic cognitions seem to represent a general mechanism of change across various PTSD treatment approaches (Kangaslampi & Peltonen, 2022 ). A recent review by Serfioti et al ( 2022 ) encompassing 15 studies indicated that both exposure-based and cognitive-based treatments led to significant reductions in guilt and anger, while an effective reduction in shame was only found in the exposure-based treatments (Serfioti et al, 2022 ). However, the review only included two studies conducted in non-Western countries (Northern Uganda and the Eastern Democratic Republic of Congo), which revealed mixed findings on trauma-related guilt.…”