Trauma-related guilt is often linked to beliefs about perceived responsibility (‘because I did this, the trauma happened’) or foreseeability (‘I should have known it was going to happen’). Often these beliefs are distorted or exaggerated, but they may also have a grain of truth that haunts your client – ‘if only I hadn’t gone to that person’s house, then I wouldn’t have been attacked’ or ‘If only I had driven my daughter to school, then the accident wouldn’t have happened’. These kind of ‘if only…’ thoughts (often called counterfactual thinking) are often a focus for rumination post-trauma, driving both guilty feelings and other PTSD symptoms.
Behind these types of thoughts often lies hindsight bias – judging our actions on what we know now rather than what we knew then. We make decisions based on the information available to us at the time. If our client knew the trauma was going to happen, they would have made different decisions. You can help you client think this through by asking them questions like: ‘when did you actually know what was going to happen?’, ‘was there any way to predict what was going to happen?’, ‘what would you have done differently if you knew what would happen?, ‘what was the main reason why you did x and not y?’
Young et al. (2021), in their excellent article on trauma-related guilt, suggest for clients to actually imagine themselves back at the point where they made the decisions they focus on then ask themselves what, in that moment, they knew or believed was going to happen. In general, this line of questioning helps clients see that they made the most reasonable decision based on the information available to them. It also sometimes reveals that they were in a ‘no-win’ situation – whatever they chose would have likely led to a bad outcome. Sometimes talking through all the possible outcomes if the client had made different decisions helps show that it would likely not have changed the outcome, or could even have made it worse.
Metaphors are another helpful way to illustrate the link between knowledge and responsibility. For example, if a child who has never seen an iron before, touches it and burns themselves, would the burn be their fault? Probably not. However, if they had been warned about the hot iron or burnt themselves before, and touched it anyway, then they might bear some responsibility for getting burned. The difference there is how much they know when making the decision to touch the iron. Norman et al., (2019) describe another helpful visual metaphor, where they construct a row of dominoes representing the series of events leading up to the trauma. The client’s decision may represent one of the dominoes, but that domino was pushed over by the ones before it and so on; in other words, the client’s single action has not caused the traumatic event, rather it is a link in the chain of causation.
It can also be helpful for clients to think about where their actions sit within a broader range of factors that lead to a particular outcome. We help them construct a responsibility pie chart, by listing all of the factors that led to a trauma occurring (considering the client’s actions last), and then allocating ‘slices of the pie’ to each relevant factor. For example, a client who was in a car accident that caused injuries to her children blamed herself because she was distracted by her baby was crying just before the accident. However, on further discussion, she realised there were many other factors that led to the accident, including the other driver who changed lanes in front of her abruptly, rain which reduced her visibility and increased her stopping distance, the fact that she was sleep-deprived because the baby had been unwell, and the road being notoriously dangerous due to confusing signage affecting the behaviour of the driver in front. Responsibility pie charts can still include a portion allocating some of the responsibility to our clients, but help by placing it in context, hence creating a more balanced perspective with all factors taken fairly into account. There is a role play demonstrating making a responsibility pie chart in this video on working with guilt (register for free if you haven't already).
Another way to access different perspectives on responsibility is to do a survey, asking people whether/how much they would blame an individual for the trauma, given what they knew at the time and the decisions they made. It can also be helpful to adapt reliving to gain a different perspective on a trauma, for example by reliving as a ‘fly on the wall’ or from a ‘bird’s eye view’. This often enables more objectivity and for the client to see all of the different elements that contributed to a trauma, often provoking more self-compassion.
If the client felt guilty at the time of the trauma, make sure you include any new information from different perspectives by reliving and updating the trauma memory. Sometimes guilty feelings only arose after the trauma, so updating the trauma memory itself may be less important. However, it can still be helpful where an intrusive memory hotspot is a trigger for guilty rumination. Either way, watch out for rumination as this can really maintain guilt.
Sometimes, clients have done something as part of their trauma which they feel violates their own moral code and which they later regret. We’ll write a future FAQ about the so-called ‘moral injury’ that can result from these events, or you can read this paper for now. In a nutshell, you can approach moral injury in a similar way to what we have described here, in terms of accessing a realistic appraisal of responsibility, as people typically overestimate their own responsibility and underestimate the role of context. However, it may also be important for clients to accept responsibility where there is genuine fault, find helpful ways to make amends, and consider how to move forward with their lives after such a trauma.
Key practice points
· Guilt often relates to distorted appraisals about being able to prevent or foresee a traumatic event and is linked to hindsight bias.
· Guided discovery techniques to address hindsight bias include Socratic questioning, metaphors, imagery exercises, responsibility pie charts and surveys.
· Reliving the trauma memory from different perspectives can also help address an inflated sense of responsibility.
Further resources:
· Young, K., Chessell, Z. J., Chisholm, A., Brady, F., Akbar, S., Vann, M., ... & Dixon, L. (2021). A cognitive behavioural therapy (CBT) approach for working with strong feelings of guilt after traumatic events. the Cognitive Behaviour Therapist, 14. https://doi.org/10.1017/S1754470X21000192
· Murray, H., & Ehlers, A. (2021). Cognitive therapy for moral injury in post-traumatic stress disorder. The Cognitive Behaviour Therapist, 14. https://doi.org/10.1017/S1754470X21000040