Academic journal article American Journal of Psychotherapy

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

Academic journal article American Journal of Psychotherapy

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

Article excerpt

Morally injurious events appear to be capable of producing posttraumatic stress disorder (PTSD) although these events may not involve actual or perceived life threat or fear, horror, or helplessness. Researchers have questioned whether exposure therapies can address PTSD that develops as a result of these events. The current report presents evidence of the effectiveness of this treatment approach for addressing posttraumatic symptoms related to a morally injurious event through a case report of a veteran of Operation Iraqi Freedom who had PTSD characterized by symptoms of guilt and shame. The veteran was successfully treated with nine sessions of prolonged exposure therapy. He reported minimal PTSD symptoms one week post-treatment and at a six-month follow-up assessment. Implications for the treatment of veterans with significant guilt and shame using exposure-based therapies, and with respect to the recent changes to the diagnostic criteria for PTSD, are discussed.

KEYWORDS: prolonged exposure; guilt; moral injury; PTSD; Operation Iraqi Freedom


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 fea- tures (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 ex- posure 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 con- stantly on guard with strong reactions to unexpected loud noises. …

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