Prolonged Exposure for Guilt and Shame in a Veteran of Operation Iraqi Freedom

Introduction

Litz and colleagues (2009) explored the psychological trajectory of exposure to morally injurious experiences, defined as “perpetrating, failing to prevent, and bearing witness to acts that transgress deeply held moral beliefs and expectations,” during military deployment to an active war zone (p. 697). The authors suggested that these events contribute to developing posttraumatic stress disorder (PTSD) and its associated features (e.g., guilt, shame, and anger), even when these events did not necessarily qualify as Criterion A stressors with respect to a formal diagnosis of PTSD under the previous iteration of the Diagnostic and Statistical Manual (DSM-IV; American Psychological Association [APA], 2000). More recently, revisions in the DSM-5 may better recognize these types of events, as exposure (directly involved, witnessed, experienced indirectly) to the traumatic event experienced is now made explicit, and the requirement that the individual experience a reaction characterized by fear, helplessness or horror was removed (APA, 2013). The symptom clusters for PTSD were also revised, and the four clusters now recognized are intrusion, avoidance, negative alterations in cognition and mood, and alterations in arousal and activity. These changes paint a broader view of what types of events may be considered as traumatic, and allow for a range of possible responses to them, which may be particularly relevant for morally injurious events.

Multiple studies suggest that among veterans events such as killing others (e.g., Maguen et al., 2010), participating in atrocities (e.g., Breslau & Davis, 1987), failing to prevent the death of a fellow soldier (e.g., Grunnert et al., 2003), and disposing of dead bodies (e.g., Ursano & McCarrol, 1990) were associated with posttraumatic stress. Litz et al. (2009) noted that the DSM-IV conceptualizations of PTSD failed to capture the complexity of moral injury arising from significant feelings of guilt and shame caused by reappraisals of actions (or lack thereof) during the initial trauma, and are manifested as intrusive, negative, and ruminative cognitions. Although revisions in the DSM-5 recognize a broader range of posttraumatic responses, there continues to be a need for research about the best treatment options for the full range of symptoms.

Prolonged Exposure (PE) Therapy for PTSD is a well-supported psychotherapy in which sustained, repeated situational and imaginal exposure to trauma-related stimuli results in symptom reduction and the extinction of conditioned fears over time (Foa, Hembree, & Rothbaum, 2007; Powers, Halpern, Ferenschak, Gillihan, & Foa, 2010). For example, a veteran with PTSD related to a specific firefight may report frequent distressing intrusions and nightmares, intense anxiety and panic in crowded situations, emotional numbing and anhedonia, and feel constantly on guard with strong reactions to unexpected loud noises. In treatment, imaginal exposure entails the patient repeatedly recounting the memory of that event in detail both in and out of session. Situational exposures would be collaboratively developed by selecting activities that the patient has been avoiding, such as going to a busy restaurant, shopping at crowded stores, watching fireworks, and assigning frequent predictable and controllable exposures to these situations for practice between sessions. Repeated exposure to these feared, but objectively safe, stimuli help the patient to recognize that he can tolerate these situations and experiences, and that he is no longer threatened by them, thereby reducing symptoms of PTSD. The robust support for exposure therapy is further highlighted by incorporating PE into the Veterans’ Health Administration (VHA) national dissemination initiative to improve PTSD treatment for active duty and retired military personnel (Rauch, Eftekhari, & Ruzek, 2012; Ruzek & Rosen, 2009).

To the extent that PE is focused on the conditioned development of fear, providers have often been reluctant to implement it with patients who present with significant guilt- and shame-mediated cognitions (Cook, Schnurr, & Foa, 2004), a contention perhaps weakly supported by research that suggests significant guilt and shame complicate treatment response to exposure therapy (Pitman et al., 1991). Consistent with this line of reasoning, Litz and colleagues (2009) recommended multifaceted interventions comprised of exposure, cognitive, and spiritual components for veterans with moral injury. Yet, it is suggested that PE can be used to address more complex symptom presentations in PTSD, including those involving notable shame and guilt (Smith, Duax, & Rauch, 2013; Rauch, Smith, Duax, & Tuerk, 2013). Given concerns about this treatment approach for presenting problems of this nature, and the strong organizational and scientific support for PE, case research illustrating how to apply PE with combat veterans with varied symptom presentations is needed. To this end, we present the case of Mr. C, a veteran Operation Iraqi Freedom (OIF) who presented with symptoms consistent with moral injury (i.e., significant guilt and shame) as well as PTSD and who was treated successfully with a brief course of PE.

Method

Case: Mr. C

Mr. C is a 27-year-old, college-educated, OIF veteran who served as a member of the Army National Guard from 1999 to 2010. In 2008 he was deployed to Iraq, where he was a convoy gunner. Despite participating in more than 180 missions, Mr. C was never directly exposed to what he perceived as life-threatening combat. Rather, his distress centered on three specific events that elicited strong feelings of guilt and shame.

First, Mr. C reported almost shooting an innocent physically and mentally handicapped Iraqi boy during a patrol in a hostile area. The event took place in the same village where a day earlier 12 soldiers were killed by a grenade thrown by a child. The child Mr. C nearly shot was crouching behind a vehicle with an object in his hand. Mr. C reported that he later found out that the object was a rock, and was bothered throughout his deployment by thoughts related to the event: “What if I had pulled the trigger and killed an innocent boy?” and “I was in charge; what if the rock had been a grenade-all of my guys would be dead.”

Second, Mr. C reported failing to prevent an improvised explosive device (IED) detonation. Mr. C was ordered to inspect and advise regarding a suspected IED. He made the call that the road was clear and the convoy proceeded. Mr. C’s convoy safely traversed the area; however, the convoy following them hit an IED, resulting in the death of two soldiers. Mr. C did not witness the event, but reported significant guilt-related thoughts (e.g., “I could have stopped that from happening”).

Third, Mr. C reported discovering his wife’s extramarital affair and experiencing persistent concerns that she would leave him while he was in Iraq. After returning from the year-long deployment, Mr. C briefly reconciled with his wife, but they later divorced. He lost his job, and then moved to the southeastern United States to “start a new life.” He reported a number of thoughts related to his relationship, including shame (e.g., “I’m worthless”), guilt (“I’m responsible that she left”) and anger (“She lied, lied, lied!”).

Assessment

Mr. C endorsed having PTSD symptoms during a routine medical appointment at a Veterans Affairs Medical Center (VAMC), and he was referred to treatment. Review of available medical records indicated that Mr. C did not have a prior psychiatric history. Mr. C was then approved for and enrolled in an ongoing clinical trial comparing in-person and telehealth delivery of PE for veterans with PTSD; he was assigned to the in-person condition (Strachan et al., 2012a). At the baseline assessment, a trained interviewer administered structured clinical interviews and Mr. C met diagnostic criteria for PTSD based on the Clinician Administered PTSD Scale (CAPS; Blake et al., 2005) and major depressive disorder (MDD) based on the Structured Clinical Interview for DSM-IV (First, Spitzer, Gibbon, & Williams, 1996). Mr. C also completed the PTSD Checklist, Military Version (PCL-M; Weathers, Litz, Herman, Huska, & Keane, 1993), Beck Depression Inventory, Second Edition (BDI-II; Beck, Steer, & Brown, 1996) and Beck Anxiety Inventory (BAI; Beck & Steer, 1993) at baseline and bi-weekly throughout the course of treatment, as well as at a six-month follow-up assessment. Mr. C’s therapist was an experienced master’s-level clinician who completed PE training with Dr. Foa and colleagues (developers of PE). All sessions were audiotaped and coded by independent raters to ensure fidelity to the protocol.

Treatment

The nine sessions of treatment provided were consistent with the model described by Foa and colleagues (2007) with a primary focus on situational and imaginal exposures. In Session 1, the therapist provided psychoeducation about common reactions to traumatic events, development of PTSD and depression, and how avoidance and withdrawal operate to maintain these symptoms. In Session 2, the therapist reviewed common reactions to trauma, presented the rationale for situational exposure and introduced the situational fear hierarchy and subjective units of discomfort (SUDs) ratings. Although SUDs ratings typically indicate the level of fear experienced in response to trauma-related stimuli, in this case, the therapist instructed the patient to use SUDs ratings to represent the intensity of negative affect more generally, as pervasive guilt was a prominent form of distress for this patient. Mr. C and the therapist collaboratively developed the list of situational exposures to target people, places, and things in which he was uncomfortable and had been avoiding. For example, he ran a 5K race that required exposure to a social situation that included both crowds and events he could not directly control.

In Sessions 3 through 9, Mr. C completed imaginal exposure to the events described above, as well as to “hotspots” associated with these memories (i.e., specific parts of those memories that were particularly distressing). Per protocol, Mr. C revisited the trauma memories in significant sensory detail for 45 minutes each session, reporting his SUDs ratings every 5 minutes. The imaginal exposures were followed by approximately 15 minutes of processing of the events discussed. During these discussions, Mr. C expressed notable guilt-related thoughts and attributions, including that he never fired his weapon while deployed, his failure to secure the safety and wellbeing of soldiers that died in the IED explosion, and his wife’s betrayal. The therapist responded to these statements with open-ended prompts, encouragement, and reflective listening, but did not explicitly address the validity of Mr. C’s beliefs, which is consistent with PE protocol. As treatment progressed, Mr. C’s narrations became more organized and he endorsed more realistic beliefs regarding his actions (e.g., “Why am I so worried about this stuff? … I did what I was trained to do”).

Mr. C’s pre- and post-treatment scores on the PCL-M, BDI-II, and BAI are shown in Table 1. Mr. C evidenced substantial reductions in his symptoms of PTSD, depression, and anxiety during the course of PE. Further, he no longer met diagnostic criteria for PTSD based on the CAPS at one week post-treatment. In addition, Mr. C’s scores on the PCL-M, BDI-II, and BAI were in the subclinical range post-treatment. Of note, per Jacobson’s and Truax’s (1991) reliable change index, Mr. C demonstrated reliable change scores, indicating his improvement was likely due to actual changes in his symptoms and not measurement error. Further, though not assessed with a specific measure, Mr. C’s report of his thoughts and perceptions of his traumatic experiences shifted from those involving significant guilt and shame to more adaptive and functional thoughts, consistent with those mentioned above.

Follow-Up

Mr. C’s scores on the outcome measures at his six-month follow-up assessment are provided in Table 1. He continued to evidence reliable changes with respect to his self-report of symptoms of PTSD, depression and anxiety, and all of his scores were in the subclinical range. In addition to this maintenance of his treatment gains, Mr. C’s report of how he was doing at his follow-up assessment further attested to the improvement in his overall functioning and quality of life. He stated he was applying for a job as a peer counselor at the United States Department of Veteran’s Affairs to help military members adjust after their return from deployments. He also served in an advisory role for a television show that wanted to provide an accurate portrayal of military personnel with PTSD. This required him to share his experiences in the military, his symptoms, and his treatment. These behaviors spoke to the significant and pervasive changes that Mr. C underwent during the course of therapy, and to his ability to maintain these gains after therapy was completed.

Discussion

Mr. C’s successful course of PE may challenge some common assumptions about the efficacy of exposure in the treatment of guilt and shame-related cognitions. Findings from this case are consistent with literature demonstrating that PE is an effective treatment for PTSD. In addition, these findings suggest that PE is effective in addressing symptoms of moral injury, such as guilt and shame. Such findings are particularly important given the recent changes to the diagnostic criteria for PTSD in the DSM-5. Given that treatment providers may begin to see more varied patient presentations due to the recognition of a broader range of traumatic events and posttraumatic responses, it is important to have evidence of effective treatment approaches for the full scope of presenting problems. The recent increase in published research in this area, including different accounts for the best ways in which to understand, and subsequently treat, PTSD (e.g., Maguen & Burkman, 2013; Rauch et al., 2013; Smith et al., 2013; Steenkamp, Nash, Lebowitz, & Litz, 2013), indicate that continued research is needed to more fully understand how shame and guilt operate with respect to moral injury and PTSD. Such work can also be used to determine how different presenting traumas (e.g., killing, inadvertent injury of others) and symptom presentations (e.g., shame, guilt) are best treated (e.g., PE, adaptive disclosure, adjunctive treatment modules).

Of note, these findings support the notion that PE may lead to modifications of maladaptive beliefs about one’s role in the traumatic event and its aftermath without targeted cognitive intervention (Foa & Rauch, 2004). Although PE does not include formal cognitive restructuring, it is a cognitive behavioral approach. Foa and colleagues (2006) have highlighted the role of maladaptive beliefs in the development and maintenance of PTSD, noting that modification of these beliefs is essential to therapeutic change. According to Kubany and Watson (2005), successful processing of fear- and guilt/shame-evoking memories required similar parameters: a) activation of and sustained engagement with guilt and shame via confrontation of identified triggers, b) retrieval of related cognitions to consciousness, and c) disclosure within a safe, therapeutic environment. Nonspecific characteristics of therapy, for example, a non-judgmental, uncondemning therapist, may create a new learning/conditioning opportunity for the reduction of guilt and shame. The patient’s assumptions about another’s negative reactions, such as condemnation and ridicule, are not present in the therapeutic setting, thereby allowing new learning to occur (e.g., “I will not be condemned,” “It wasn’t my fault”). Inclusion of PTSD-related measures of shame, guilt, or anger (e.g., Posttraumatic Cognitions Inventory; Foa, Ehlers, Clark, Tolin, & Orsillo, 1999) in future research should help to provide a more accurate assessment of these symptom changes during PE.

This case report provides an illustration of how PE may be used to treat patients with PTSD who present with significant shame, guilt, and moral injury. As service members are more likely to confront morally injurious experiences during deployment than life-threatening combat (e.g., Hoge et al., 2004), it remains to be seen whether this case represents a typical or an atypical PTSD treatment referral of an OIF veteran. It is important that such experiences are recognized as potentially traumatic under the DSM-5. To the extent that PE is brief, parsimonious, and effective for multiple symptom presentations, and is increasingly available through the VA system, this intervention may provide a cost- and time-efficient alternative over multi-component interventions for this full range of patient presentations (Rauch et al., 2013).