Combat-related guilt and the mechanisms of exposure therapy

Why Do Veterans Not Respond as Well as Civilians to Trauma-Focused Therapies for PTSD?

ABSTRACT

This column first reviews evidence that veterans have poorer response to trauma-focused therapies for PTSD compared to civilians. We then consider several explanations for this trend, starting with gender as a possible confounding variable. We also examine other hypotheses, including the effects of the military acculturation process, the unique influences of military traumas, such as combat and military sexual traumas, and the roles of traumatic brain injuries (TBIs) and moral injury. Future research, we conclude, must determine whether gender explains the differences in trauma-focused therapy response. If so, then the underlying reasons must be further explored. If not, then we must determine the unique characteristics of the veteran population that make it more resistant to treatment. Mining these elements will help us adapt our trauma-focused therapies to better help this population and close the response-rate gap.

Trauma-Related Shame and Guilt as Prospective Predictors of Daily Mental Contamination and PTSD Symptoms in Survivors of Sexual Trauma

Mental contamination (MC), the experience of dirtiness in the absence of a physical contaminant, has established links with posttraumatic stress disorder (PTSD). Shame and guilt have well-documented relationships with symptoms of PTSD and may play a role in the development and maintenance of MC. The present study examined whether trauma-related shame and guilt prospectively predicted daily MC and symptoms of PTSD among 41 women with a history of sexual trauma. Women completed baseline and twice-daily assessments of MC and symptoms of PTSD over a 2-week period and baseline measures of trauma-related shame and guilt. Two sets of hierarchical mixed linear regression models examined individual and combined fixed effects of baseline trauma-related guilt (guilt cognitions and global guilt) and shame in predicting daily trauma-related MC and symptoms of PTSD. Trauma-related shame positively predicted both daily MC and PTSD. This association remained robust even when accounting for the experience of trauma-related guilt. Neither trauma-related guilt cognitions nor global guilt predicted daily MC or PTSD. While other studies have addressed shame related to sexual assault, this is the first study to demonstrate a positive prospective relationship between shame and trauma-related MC. Findings regarding PTSD and shame are consistent with a growing literature. Further research is needed to better understand the temporal relationships between trauma-related shame, MC, and symptoms of PTSD, including how these variables interact and change over the course of PTSD treatment. A better understanding of the factors influencing the development and maintenance of MC can inform efforts to more easily target and improve MC, and subsequently PTSD.

The wide variety of reasons for feeling guilty in adults: findings from a large cross-sectional web-based survey

BACKGROUND

Experiencing some sort of guilt is a common phenomenon in adulthood. As feeling guilty is usually unpleasant and may even lead to further negative psychological consequences like depression, the aim of this study was to provide comprehensive information on the reasons for such feelings in adults.

METHODS

A cross-sectional web-based survey was conducted between May 2019 and April 2020, collecting qualitative information on reasons for feeling guilty in n = 604 adults (mean/SD age = 45.3/16.4 years; n = 346/57.3% women, n = 255/42.2% men and n = 3/0.5% adults without identification with a particular gender). Stated reasons were inductively classified into (super-)/categories, and information on frequency and percentage (total, gender- and age-specific) for each of these (super-)/categories was provided.

RESULTS

Participants altogether stated 1515 reasons for feeling guilty that were classified into 12 supercategories and 49 categories. "Telling lies/withholding truth/information" followed by "Not spending (enough) time with family (members)/Not taking (enough) care of family (members)/not being there for family (members)" were the most frequent categories of reasons for feeling guilty in the sample. Guilt feelings explicitly referring to "religious beliefs" or a "subjectively perceived more general responsibility'" (e.g., for society, humankind, problems of the world), by contrast, were of minor importance. Male and female participants as well as participants of different ages showed similarities but also several differences in stated reasons for feeling guilty. Female participants, for example, more often experienced feelings of guilt related to family members, children and to some kind of general responsibility for the wellbeing of others, whereas male participants felt guilty more often because of some kind of misconduct/mistakes being made or because of difficulties in marriage/relationship.

CONCLUSIONS

Adults can feel guilty for a wide variety of different reasons. Most reasons seem to be rather concrete (e.g., related to concrete negative self-attributions/flaws or to concrete social situations with concrete individuals). There also seem to be some age- and gender-related differences in reasons for feeling guilty.

COVID-19 and tourism stakeholders: experience, behaviour and transformation

Purpose

The tourism sector’s fragility lends significance to mental health and wellbeing, especially amongst workers in the hotel and tourism sectors. However, stakeholders’ subjective wellbeing and mental health in these sectors due to the coronavirus disease 2019 (COVID-19) pandemic remain under-researched, especially for destinations with unique selling propositions (USPs). Thus, this study investigates the effects of the worldwide COVID-19 pandemic on various stakeholders in Kerala, India. In particular, the authors assess the mental health and welfare of those involved in the tourism sector with an eye on how the COVID-19 pandemic has influenced the field’s psychological and technical developments.

Design/methodology/approach

This study employs an ethnographic approach to understanding the idiosyncratic experiences of stakeholders using in-depth interviews (n = 68), focus group interviews (n = 3) and participant observation for 14 months. Reflexive thematic analysis was used to analyse the data.

Findings

The findings reveal the shifting perceptions in the tourism sector’s workforce by detailing various societal, technical and physical transformations, especially amongst the younger generations. The resultant psychological mapping generates a framework of the emotional perspectives of stakeholders during each stage of the pandemic. This study also highlights the urgency of crisis-management training for the workforce.

Originality/value

The COVID-19 pandemic has affected all spheres of global business, resulting in unprecedented challenges in both personal and professional life. The sector’s fragility lends significance to mental health and wellbeing, especially amongst workers in the hotel and tourism sectors. However, the subjective wellbeing and mental health of stakeholders in these sectors due to the COVID-19 pandemic remain under-researched, especially for the developing destinations with USPs.

Reductions in guilt cognitions following prolonged exposure and/or sertraline predict subsequent improvements in PTSD and depression

BACKGROUND AND OBJECTIVES

Reduction of trauma related negative cognitions, such as guilt, is thought to be a mechanism of change within PTSD treatments like prolonged exposure (PE). Research suggests PE can directly address guilt cognitions. However, whether pharmacotherapies for PTSD can remains unclear.

METHODS

Data from a randomized controlled trial of PE plus placebo (PE + PLB), sertraline plus enhanced medication management (SERT + EMM), and their combination (PE + SERT) in 195 Veterans from recent wars was analyzed.

RESULTS

The unadjusted means and mixed-effects model showed guilt decreased significantly over the follow-up time as expected; however, contrary to our hypothesis, PE conditions were not associated with greater reductions in guilt than the SERT + EMM condition. As hypothesized, week 12 reduction in guilt predicted post-treatment (weeks 24-52) reduction in PTSD and depression, but not impairments in function.

LIMITATIONS

Generalizability of findings is limited by the sample being comprised of combat Veterans who were predominantly male, not on SSRI at study entry, willing to be randomized to therapy or medication, and reporting low levels of guilt. To reduce differences in provider attention, SERT + EMM was administered over 30 min to include psychoeducation and active listening; it is unknown if this contributed to effects on guilt.

CONCLUSIONS

PE + PLB, SERT + EMM, and PE + SERT were equally associated with reduction in trauma related guilt. Reducing trauma related guilt may be a pathway to reducing PTSD and posttraumatic depression symptoms. Further study is needed to determine how best to treat trauma related guilt and to understand the mechanisms by which guilt improves across different treatments for PTSD.

COVID-19 event strength, psychological safety, and avoidance coping behaviors for employees in the tourism industry

The impact of COVID-19 on the emotions or behaviors of employees in tourism enterprises would be worthwhile for investigation since COVID-19 has harmed not only people's health and lives but also most tourism enterprises. By identifying the effect of COVID-19 event strength on avoidance coping behaviors, the behaviors isolated from customers unlikely beneficial for tourism enterprises, we not only revealed that COVID-19 event strength indirectly affects avoidance coping behaviors through either the fear of external threat or psychological safety, but also disclosed that supervisor safety support would moderate the effect of psychological safety on such coping behaviors. We argue that understanding potential causes, such as the fear of external threat and psychological safety, and identifying possible solutions, like supervisor safety support, may be key factors for restarting tourism enterprises successfully under the severe impact of the COVID-19 pandemic.

Trauma-related guilt and posttraumatic stress disorder symptoms in military veterans: The role of psychological inflexibility

A growing body of evidence has shown consistent support for the association between trauma-related guilt and posttraumatic stress disorder (PTSD). However, factors that account for this association are not well understood. The present study examined psychological inflexibility as a potential mediator between trauma-related guilt and PTSD symptoms in a sample of U.S. military veterans. Secondary data analyses from a larger randomized control trial were conducted. Specifically, three separate mediation models were used to test if psychological inflexibility mediated the association between trauma-related guilt (guilt cognitions, guilt distress, overall guilt) and PTSD symptoms in 85 treatment-seeking veterans diagnosed with PTSD and alcohol use disorder. All three components of trauma-related guilt were positively associated with both psychological inflexibility and PTSD symptoms; psychological inflexibility was also positively associated with PTSD symptoms. Furthermore, psychological inflexibility partially mediated the association between all facets of trauma-related guilt and PTSD severity. These findings provide further support for the association between trauma-related guilt and PTSD and also provide insight into one mechanism linking trauma-related guilt to PTSD symptoms. Thus, psychological inflexibility may serve as an important intervention target for veterans with comorbid PTSD and alcohol use disorder struggling with trauma-related guilt.

Comparing Exposure- and Coping Skills-Based Treatments on Trauma-Related Guilt in Veterans With Co-Occurring Alcohol Use and Posttraumatic Stress Disorders

Posttraumatic stress disorder (PTSD) and substance use disorders (SUD) commonly co-occur, and this comorbidity (PTSD-SUD) is associated with more severe symptoms and functional impairment than either disorder alone. Growing evidence indicates that trauma-related guilt, typically concerning negative appraisals of one's actions or inaction during a traumatic event, is associated with PTSD, depression, suicidality, and, possibly, substance use. The present study examined whether integrated treatment for PTSD-SUD was effective in reducing trauma-related guilt as measured by the Trauma-Related Guilt Inventory. Data were drawn from a randomized clinical trial comparing the effectiveness of two integrated therapies on treatment outcomes in a sample of U.S. veterans (N = 119) with comorbid PTSD and SUD. Participants were randomized to receive either Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE; n = 63) or Seeking Safety (SS; n = 56). The results indicated that global guilt decreased over time for the whole sample. However, there was a significant Treatment × Time interaction, such that participants in the COPE condition reported lower rates of global guilt, d = 0.940, over time compared to those in the SS condition, d = .498. To our knowledge, this was the first study to examine the effects of integrated PTSD-SUD treatment on trauma-related guilt. The findings highlight that exposure-based, trauma-focused treatment for comorbid PTSD-SUD can be more effective in decreasing trauma-related guilt, with potentially longer-lasting effects, than non-exposure-based treatment, adding evidence that patients with PTSD-SUD should be offered such treatment.

Virtual reality exposure versus prolonged exposure for PTSD: Which treatment for whom?

BACKGROUND

The majority of studies comparing active psychological treatments for posttraumatic stress disorder (PTSD) do not find significant differences at posttreatment. This was the case in a recent trial examining prolonged exposure (PE) and virtual reality exposure (VRE) among active-duty soldiers with combat-related PTSD. Matching individual patients to specific treatments provides a potential avenue to improve significantly the public health impact of effective treatments for PTSD. A composite moderator approach was used to identify profiles of patients who would see superior PTSD symptom reduction in VRE or PE to inform future treatment matching.

METHODS

Active duty U.S. army soldiers (N = 108) were enrolled in a randomized clinical trial comparing VRE and PE in the treatment of PTSD stemming from deployments to Iraq or Afghanistan. Eighteen baseline variables were examined to identify treatment response heterogeneity in two patient groups: those with a superior response to PE and those with a superior response to VRE. The final composite moderator comprised four of 18 baseline variables.

RESULTS

Results revealed that patients who were predicted to see greater PTSD symptom reduction in VRE were likely to be younger, not taking antidepressant medication, had greater PTSD hyperarousal symptoms, and were more likely to have greater than minimal suicide risk.

CONCLUSIONS

Results suggest that treatment matching based on patient profiles could meaningfully improve treatment efficacy for combat-related PTSD. Future research can build on these results to improve our understanding of how to improve treatment matching for PTSD.