ارتکاب ادراک در طول حوادث: پیشنهادات بالینی از کارشناسان در مواجهه درمانی طولانی مدت

Prolonged exposure therapy (PE) is a treatment that has proven effectiveness in reducing the symptoms of posttraumatic stress disorder (PTSD) and related psychopathology. Providing PE to trauma survivors with PTSD, particularly related to combat trauma, often involves addressing guilt or shame related to their contextually appropriate use of violence and lethal force. In this paper, we present 4 clinical case vignettes in order to define the concept of perceived perpetration, and offer clinical suggestions for assessment and treatment with PE. Specifically, we examined issues such as identifying what type of traumatic events are appropriate for the use of PE, how to approach issues surrounding actions that could be perceived as perpetration, and attending to trauma-related guilt or shame.

Prolonged exposure therapy (PE), a type of exposure therapy, is an empirically supported treatment for PTSD and related psychopathology, such as depression, anger, and guilt (Cahill et al., 2003, Foa et al., 1999, Foa et al., 2005, Hembree et al., 2005, Paunovic and Öst, 2001, Rauch et al., 2009, Resick et al., 2002, Rothbaum et al., 2005, Schnurr et al., 2007 and Tuerk et al., 2011). In response to the need to provide effective treatments to men and women who have served in the Armed Forces, the most recent U.S. Department of Veterans Affairs and Department of Defense (VA/DoD) treatment guidelines recommended exposure therapy as a first-line intervention for PTSD (Friedman, 2006, Institute of Medicine, 2007 and U.S. Department of Veterans Affairs and Department of Defense, 2010). In addition, the Veterans Health Administration is conducting a nationwide rollout to train clinicians to be providers of PE (Rauch, Eftekhari, & Ruzek, 2012). Military personnel are at a high risk for using lethal force and perpetrating harm (both intentional and unintentional) while serving in a combat zone. A recent analysis of data collected as part of Operation Iraqi Freedom postdeployment screening program found that 40% of soldiers reported killing or being responsible for killing during their deployment (Maguen et al., 2010). In addition, after controlling for combat exposure, killing emerged as a significant predictor of PTSD symptoms, alcohol abuse, anger, and relationship problems. Higher rates of PTSD among Vietnam veterans have also been reported among those directly involved in atrocities (MacNair, 2002). In response to the complex moral and ethical challenges that modern warfare poses for service members, Litz et al. (2009) have introduced the concept of “moral injury.” They conceptualize potentially morally injurious events as those that involve “perpetrating, failing to prevent, or bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations” (p. 700). Given that events such as these may unfortunately be commonplace for veterans, Litz et al. suggest that it is important for clinicians to expand their repertoire in order to fully address the psychological sequelae stemming from morally injurious events. Accordingly, they propose a modified CBT intervention that addresses moral injury (see Steenkamp et al., 2011, for intervention). Although they include an abbreviated exposure component in this treatment, they argue that traditional exposure-based treatment focusing on fear and anxiety-based PTSD symptoms may not adequately address the guilt and shame that may follow from morally injurious events. This assertion, however, is not consistent with research showing that PE results in significant reductions in guilt as well as PTSD symptoms (Foa and Rauch, 2004 and Resick et al., 2002). Traumatic events that involve morally injurious events are likely to elicit debilitating guilt and shame. Accordingly, clinicians utilizing PE to treat symptoms of PTSD must also attend to these negative moral emotions. In a review of the literature on guilt, Tilghman-Osborne, Cole, and Felton (2010) found discrepancies regarding the relationship of guilt to psychopathology and proposed that these resulted from variable definitions and measurements of the construct of guilt. The reviewers concluded that guilt is a complex construct involving both affective and cognitive components, real or imagined moral transgression, and behavioral self-blame. For the purposes of this paper, we will conceptualize guilt similarly to Tilghman-Osborne et al. (2010) as thoughts and feelings resulting from a perceived moral transgression with behavioral but not characterological self-blame. Feelings of responsibility and remorse may be part of guilt along with a desire to make reparations. Litz et al. (2009) concluded that guilt is associated with a decrease in committing similar offenses in the future, and it often facilitates making amends. Tangney, Stuewig, and Mashek (2007) argue that guilt is adaptive when individuals acknowledge their moral transgression and take appropriate responsibility. They argue that guilt is maladaptive when it is fused with shame and produces feelings of contempt and disgust for a defective self. In contrast to guilt, which involves a negative evaluation of a specific behavior in a situation (I did something bad/wrong that I regret), the moral emotion of shame entails a negative evaluation of the global self (I am a bad person; Tangney et al., 2007). In their review of the existing literature on shame and guilt, Tangney et al. concluded that shame is a more painful and damaging emotion to one's mental health because the core of the self is the object of the condemnation rather than a specific behavior. Shame often results in one feeling exposed and expectant of others’ disapproval or negative judgment. While guilt can lead to a desire to make amends, shame is linked to disruption of empathic connection and the tendency to withdraw interpersonally and focus on internal distress. Feelings of shame are also positively correlated with anger, hostility, expressions of anger in destructive ways, and externalization of blame. The distressing emotion of shame is difficult to resolve as it reinforces defective self-views. Clinicians providing treatment for PTSD that has resulted from traumatic events that elicit feelings of shame and maladaptive shame-infused guilt, such as potentially morally injurious traumas, must be intentional in addressing patients' distress related to these emotions. It follows that a goal for treatment would be to “unfuse” the shame from the guilt and assist the trauma survivor in acknowledging appropriate levels of responsibility for their action or inaction. Specific recommendations for how to utilize PE for this purpose will follow. In order to address the concern that exposure-based treatments for PTSD may not sufficiently address symptoms of guilt and shame stemming from morally injurious traumas, we present clinical suggestions for how to address these issues when providing PE. In particular, we will focus on morally injurious traumas that involve acts of perceived perpetration and discuss how PE can address resultant PTSD and associated guilt and shame. For the purpose of this paper, we define perceived perpetration as occurring when a trauma survivor, in the context of his/her trauma, (a) acted with potentially violent and/or lethal force or failed to act when violence was occurring to others, and (b) interprets his/her behavior as perpetration or as violating his/her moral code and, (c) acted as a consequence of the trauma context and not as a premeditated act or with instrumental intent to victimize. After presenting four clinical vignettes of trauma survivors struggling to recover from traumas involving perceived perpetration, we provide guidance on how to approach assessment and provision of PE in cases involving perceived perpetration.

In this article we addressed the clinical concept of “perceived perpetration” as it applies to traumas commonly reported by veterans. Specifically, we presented case examples from our clinical experiences and provided clinical suggestions for assessing and treating PTSD via PE. We view the initial assessment of PTSD as critical in developing a clinically appropriate treatment plan for working with veterans reporting perceived perpetration traumas. Given the complicated nature of combat theater traumas, it is important to evaluate the presence of potentially psychopathic traits in a nonjudgmental way. For patients who have a longer-standing history and pattern of antisocial acts, absence of guilt, overconcern for negative consequences of disclosure, PTSD is not likely a primary diagnosis and treatment via PE is not appropriate. These individuals would likely be better served with behavior modification, remediation, and rehabilitation treatment programs. In contrast, patients who perpetrated harm (intentionally or unintentionally) within the context of combat and who express significant guilt, remorse, and a history of prosocial behaviors outside of the war context, are more likely suffering from primary PTSD for which PE would be indicated. Moreover, assessing the patient's emotions before, during, and after the traumatic event can help to uncover core emotions of fear and horror and helplessness that assist in differential diagnosis of PTSD. Once a careful diagnosis has been made, we provided clinical suggestions for applying PE in working with combat veterans with perceived perpetration traumas. Specifically, clinicians can address perceived perpetration within each component of PE: psychoeducation, imaginal exposure, processing, and in-vivo exposure. The thread common to these suggestions is helping patients to fill in the contextual details of their traumas and receive corrective feedback from their environment in order to reduce the intensity of their guilt and allow for the dissipation of negative self-views may be contributing to feelings of shame. In conclusion, the unique context of combat requires clinicians to become more adept at assessing and treating PTSD involving traumas that are not commonly observed among civilians. As always, a nonjudgmental and empathic stance will help to facilitate patients’ full disclosure of traumatic events, thereby making treatment planning more appropriate and refined. While our primary focus has been combat trauma, the concept of perceived perpetration is relevant to other trauma survivors as well, such as trauma survivors who used lethal force in self-defense. Thus, we encourage clinicians working with veterans and trauma survivors who disclose perceived perpetration traumas to use PE to address PTSD and related guilt or shame.