Though PTSD is currently classified as an anxiety disorder, an array of other emo-tions, including sadness, guilt, shame, and anger, are frequently sources of distress for trauma survivors (Holmes, Grey, & Young, 2005). Research on the interplay of various trauma-related emotions is in its early stages. Emotions other than anxi-ety not only are frequent and prominent aspects of peri-traumatic responding, they also are likely to play a significant, albeit as yet under-studied, role in maintaining the disorder. For example, Andrews et al. found that shame and anger experienced in the first month after a criminal assault were the strongest predictors of PTSD 6 months later (Andrews, Brewin, Rose, & Kirk, 2000). Therapists should, therefore, assess these emotions and be prepared to grapple with them in addition to anxiety.
Identifying these emotions at the outset of treatment will be conducive to develop-ing a treatment plan aimed for success. This can be done with specific assessment instruments, such as the Trauma-Related Guilt Inventory (Kubany et al., 1996), the guilt and anger items of the Clinician Administered PTSD Scale (CAPS) (Blake et al., 1990), or unstructured clinical interview. Therapists should listen carefully for trauma-related beliefs associated with anger, guilt, or shame (e.g., “It shouldn’t have happened that way,” “It was all my fault”) that patients may express during the assessment process or during imaginal exposure.
Non-anxiety emotions have the potential to interfere with the effectiveness of exposure therapy (Foa et al., 1995; Grunert, Weis, Smucker, & Christianson, 2007) or decrease the patient’s motivation to disclose or confront specific trauma-related beliefs or memories. If the patient exhibits a pattern of initial activation of anx-iety during exposure followed by little or no decrease in reported distress over time (i.e., no within-session extinction), the therapist should consider the possibility that reported distress predominantly reflects other emotions. The absence of facial expressions of fear is a further clue and is predictive of poor outcome from expo-sure therapy (Foa et al.). Failure to show reductions in peak anxiety across sessions is another indicator that other emotions may be activated during exposure, influenc-ing ratinfluenc-ings of distress and interferinfluenc-ing with fear reduction. It is important to detect these emotions when they emerge in order to facilitate processing them effectively.
Sadness
Intense sadness often is associated with depression, a comorbid problem for approx-imately 50% of patients seeking treatment for PTSD (Zayfert, Becker, Unger, &
Shearer, 2002). The dilemma for the clinician in treating comorbid depression with
PTSD is whether the depression is so severe that it warrants targeted treatment prior to trauma-focused CBT, or whether it will resolve when PTSD is successfully ame-liorated (Foa et al., 2005). Examining the issues underlying the individual’s sadness will help the clinician decide how to manage sadness and depression and avert treat-ment failure due to worsening depression during trauma-focused treattreat-ment. Sadness can be associated with grief over a loss incurred during the trauma (such as Tom’s grief over the death of his army buddy). Sadness that is connected to grief is likely to habituate during exposure (Shear, Frank, Houck, & Reynolds, 2005) and need not be an obstacle to proceeding with either exposure or cognitive therapy; indeed, protocols for cognitive processing therapy often contain an optional session specifi-cally addressing traumatic grief. If, however, the grief is about loss of a meaningful life experience or role, such as the loss of one’s childhood or the loss of the sol-dier’s role, then the therapist may also consider strategies aimed at recreating life meaning.
Sadness may also be related to loss of self-worth in connection with traumatic events, and in this way is often connected to shame and/or guilt. For example, for most of his life, Tom had a sense that he was “no good,” something he repeatedly heard from his father. This sadness was related to shame. Since returning from Iraq, he has struggled with feeling responsible for his buddy’s death, and this magnified his low appraisal of his own worth (“I didn’t deserve to live when I let him die”), an example of sadness related to guilt. Sadness related to guilt and shame about aspects of the trauma can often be successfully reduced using cognitive restructuring to target maladaptive beliefs about self-worth connected to the trauma.
Shame and Guilt
Guilt and shame are two distinct, though related, emotions that are often experi-enced in relation to traumatic events. Guilt involves feelings of remorse or regret accompanied by the belief that one has done something “wrong” or “bad” and that one should have thought, felt, or acted differently according to internal standards (Kubany & Watson, 2003). Guilt is distinct from shame in that the focus is on behavior, while the self-concept remains intact. In contrast, shame, typically asso-ciated with an urge to hide from others, is a more devastating and painful emotion in which the entire self, not just the behavior, is negatively evaluated. Shame theo-retically involves feelings of worthlessness and powerlessness, and shame (but not guilt) is associated with depression (Tangney, Wagner, & Gramzow, 1992).
Individuals who feel intense guilt or shame about a traumatic event may be highly motivated to avoid thinking about the event, thereby interrupting processing of the memory. Guilt and shame interfere with engagement with anxiety, so when they become the focus during imaginal exposure they can prevent new learning, thereby impeding therapy progress (Riggs et al., 2006). In some instances, disen-gagement may take the form of dissociating completely from the memory and even from the present reality, such that the patient is no longer mentally present in the therapist’s office. It is important to note that guilt may be present but may not acti-vate during exposure therapy, thus causing no interference with treatment. Indeed,
outcome studies have demonstrated that exposure therapy reduces overall levels of guilt (Taylor, 2004). There is some evidence, however, that cognitive process-ing therapy may be more efficacious than exposure for decreasprocess-ing trauma-related guilt related to hindsight bias or perceived lack of justification for one’s behavior (Resick et al., 2002).
Anger
Clinical lore long held that angry patients were not good candidates for exposure therapy (Jaycox & Foa, 1996). In support of this, Foa et al. (1995) found that when anger is activated during exposure the patient disengages from anxiety and distress ratings elevate but do not diminish, a process which impedes the effectiveness of exposure therapy. As in the case of guilt, however, anger that does not activate dur-ing exposure may not impede treatment success. Evidence suggests that patients with high levels of anger often benefit from exposure and are likely to experience reduction in anger as a result (Cahill, Rauch, Hembree, & Foa, 2003). Thus, as with guilt, it is important for therapists to be aware of the presence of anger and its poten-tial for interfering with treatment and then to monitor possible effects anger may have on treatment progress. Clues that a patient is experiencing anger during imag-inal exposure include non-verbal behavior such as facial expressions, tone of voice, or actions. Also, when anxiety ratings do not decline during exposure, the clinician may inquire whether the ratings reflect anger. For example, during exposure to a memory of being abused as a child, the therapist noted that Tom’s distress ratings did not change over several sessions despite homework compliance. The therapist asked about his thoughts and feelings during exposure, and Tom reported that he was angry with his father for having ruined the family. As a result of his focus on anger, he no longer felt anxious when recalling this memory.
Overcoming Guilt, Shame, and Anger
When guilt, shame, or anger is prominent, the therapist should consider whether to include cognitive restructuring or imagery rescripting (Arntz, Tiesema, & Kindt, 2007; Grunert et al., 2007; Rusch, Grunert, Mendelsohn, & Smucker, 2000) in the initial treatment plan, or pending response to exposure interventions. Although imagery rescripting can take various forms, the concept entails altering disturb-ing images associated with the trauma in a manner that enhances the individual’s sense of mastery or control of the experience. Recent data suggest that augmenting exposure with imagery rescripting produces greater effects on anger, guilt, and pos-sibly shame (Arntz et al., 2007). If exposure is implemented first and the patient’s anxiety fails to extinguish across exposure sessions, the therapist should assess whether other emotions have been activated. If guilt or shame has been activated, the therapist should consider postponing exposure and using cognitive restructur-ing or addrestructur-ing imagery rescriptrestructur-ing to decrease guilt and shame. If re-experiencrestructur-ing symptoms persist, resume exposure.
If anger has been activated, the therapist should start by encouraging the patient to “refocus” away from the anger to the primary emotions associated with the mem-ory (Riggs et al., 2006). It is often helpful to validate the empowering effects of anger. For most people, anger feels better than feeling frightened or vulnerable. In particular, men are socialized to view emotions such as sadness and fear as signs of weakness; in contrast, anger is more socially acceptable for men to feel and express.
If the patient is unable to maintain focus away from the anger, the therapist should next inquire as to its source. Often, patients are able to identify another emotion – such as loss, shame, or powerlessness – that underlies the anger and that the anger allows them to avoid. If the primary emotions associated with the memory can extin-guish via exposure (e.g., fear, sadness), the therapist can encourage the patient to focus on the underlying emotion instead of the anger. With his therapist’s help, Tom was able to identify a strong sense of loss of his childhood and his family life underlying the anger that emerged during exposure to a memory of abuse. After acknowledging and validating this loss, Tom was able to focus on the fear he felt during that episode and exposure resumed. If shame or guilt underlies anger, cogni-tive restructuring may facilitate processing of those emotions so that exposure may resume. Validating anger should always be part of this process. In some cases, focus-ing on acceptance of past wrongs, injustices, or losses and examinfocus-ing consequences of maintaining attention on anger can help the patient to “let go.”
Sadness, anger, shame, and guilt that emerge in response to PTSD symptoms or the decision to seek help often are involved in perpetuating PTSD symptoms and can interfere with treatment success (Ehlers & Clark, 2000). Many cultures (for example, the military) have expectations that individuals should be able to tolerate significant discomfort and seeking mental health care is a sign of individual weak-ness. Patients may feel ashamed of their perceived weakness, sad about the fact that they need treatment, or guilty for not coping more effectively. Clinicians should listen for statements or questions about the implications of seeking mental health care (e.g., “I can’t believe I’m in a place like this;” “Does this mean I’m crazy?”) or ask directly about such attributions. Often, validation coupled with psychoeducation can alleviate anxiety about the help-seeking process. Cognitive restructuring may be necessary to decrease distress and increase the likelihood of treatment completion.