Evidence-Based Trauma Treatment: Problems With a Cognitive Reappraisal of Guilt

Across the U.S. Veterans Affairs health care system, there have been programmatic initiatives to implement evidence-based psychotherapies (EBPs) for posttraumatic stress disorder, such as Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) (Chard, Ricksecker, Healy, Karlin, & Resick, 2012). Several thousand clinicians have been trained, which makes these manualized treatments some of the most widespread and influential clinical training tools in the country. This article contends that these approaches are inadequate in responding to what is arguably the most important impact of military trauma: an enduring sense of guilt, remorse, and regret. A dialogue from the CPT training manual is highlighted as an example of how a therapist's assumptions about, inattention to, or underestimation of clients' moral horizons can cause harm. The author situates this critique in a broader discussion of some of the ways that psychology in general has dismissed guilt by divorcing it from the traditional contexts and value systems that give it meaning. This includes the cognitive-behavioral propagation of guilt as the byproduct of an irrational and unhelpful cognitive style, and recent research on moral injury conceptualization and treatment.