Thinking Errors, Faulty Conclusions, And Cognitive Therapy For Trauma-Related Guilt
By Edward S. Kubany, Ph.D., ABPP
NCP Clinical Quarterly 7(1): Winter 1997
There is growing recognition that trauma survivors’ explanations of their involvement in trauma may contribute to posttrauma symptomatology and interfere with the process of recovery (1-3). These explanations often revolve around cognitive aspects of guilt, which is conceptualized as consisting of negative affect plus a set of interrelated beliefs about one’s role in a negative event (2,4,5). My colleagues and I have identified four cognitive dimensions or components of guilt, which (a) perceived responsibility for causing a negative outcome, (b) perceived lack of justification for actions taken, (c) perceived violation of values, and (d) a belief that one knew what was going to happen before the outcome was observed.
Several investigators have noted that trauma survivors tend to distort or exaggerate the importance of their roles in trauma (2,3,6), and trauma survivors repeadedly draw from four kinds of faulty conclusions -- each of which involves distortion of a cognitive component of guilt (2). First, many trauma survivors exaggerate the degree to which they were responsible for causing traumatic- related outcomes. Second, many trauma survivors think that their actions during the trauma were less justified than would be indicated by objective analyses of the facts. Third, many trauma survivors conclude that they are guilty of wrongdoing even though their intentions were consistent with their values. Fourth, trauma survivors often conclude that they "knew" what was going to happen before it was possible to "know." .
Thinking Errors That Lead To Faulty Conclusions About One’s Role In Trauma
We have identified 15 thinking errors which can lead trauma survivors to draw faulty conclusions about how justified, responsible, and guilty of wrongdoing they were when the trauma occurred. Helping clients correct these thinking errors is a major focus of our structured cognitive therapy approach for treating trauma-related guilt (2,8). The 15 thinking areas are discussed in considerable detail elsewhere (2) and will be described briefly in this article. Seven of the thinking errors may contribute to faulty conclusions about causal responsibility; four of the them may contribute to faulty conclusions about justifiability for actions taken; three of them may contribute to faulty conclusions about wrongdoing; and one of the thinking errors may contribute to all of the faulty conclusions.
Thinking Errors That Contribute To Faulty Conclusions About Degree Of Responsibility
Faulty beliefs about pre-outcome knowledge caused by hindsight bias.
Hindsight bias (which is akin to Monday morning quarterbacking) occurs when knowledge about event outcomes biases or distorts beliefs about knowledge possessed before outcomes were known (2,7,9). Common among trauma survivors, hindsight-biased thinking leads many trauma survivors to believe falsely that they knew what was going to happen before it was possible to know or that they dismissed or overlooked clues or signs that "signaled" what was going to occur. Because they believe they "should have" acted on this "knowledge" to prevent some tragedy, many trauma survivors then conclude that to some extent they caused the tragedy. An incest survivor who believed she was partly responsible for causing her own abuse expressed insight about this thinking error when she said, "I was putting my 38-year old mind in my 12-year old mind." She had been remembering herself as having better judgment, at age 12, than she was capable of having.
Obliviousness to totality of forces that cause traumatic events.
Trauma survivors often seem to be oblivious to the fact that traumatic events often have multiple sources of causation and make no effort to assess the relative contributions of causal factors outside of themselves. For example, one Vietnam veteran who considered himself to be 98% responsible for the death of a buddy from sniper fire had completely ignored causal contributions of the enemy, other soldiers in his unit, the chain of command, the buddy, himself, and politicians in the U.S. who were responsible for our being in Vietnam.
Equating a belief that one could have done something to prevent the traumatic event with a belief that one caused the event.
Many trauma survivors mistakenly equate beliefs that they "could have prevented" a traumatic event with beliefs that they caused the event. Even if such individuals "could have" prevented the traumatic outcomes, it does not mean that they actually caused them. This explanation made sense to a formerly battered woman who said, "That’s for sure! I didn’t pull his fist into my face."
Confusion between responsibility as accountability (e.g., one’s "job") and responsibility as power to cause or control outcomes.
Many trauma survivors think they caused negative outcomes because they equate some job or role assignment with an ability to determine outcomes. For example, one former platoon leader told me he was responsible for the deaths of men in his unit because "I didn’t do my job. I was supposed to keep my men alive." He confused his social role or position (he was "in charge") with what he was actually capable of accomplishing or causing. This thinking error may be particularly prevalent among parents who have lost children to homicide, suicide, accidents, or serious illness (10).
Thinking Errors That Contribute To Faulty Conclusions About Justification For Actions Taken
Failure to recognize that different decision-making "rules" apply when time is precious than in situations which allow extended contemplation of options.
During many traumatic events, time for brainstorming or extended evaluations of alternatives is not available, and decisions are often based on an almost automatic, summarization and priorization of options. In fact, failure to act quickly during a crisis can be very risky. For example, a person trapped in a burning building faces increasing risk for every second it takes to decide how to escape. What may seem to have been an "obviously better decision" after years of rehashing may not have been obvious at all during the stressful, precious moments available for deciding what to do during the trauma.
Weighing the merits of actions taken against options which only came to mind later.
Sometimes, after much rehashing, survivors think of something that might have prevented a tragic outcome, had it occurred to them during or prior to the trauma. Pitman and his colleagues (11) described the case of a Marine veteran who realized during therapy that he might have saved the life of a buddy during a Vietnam battle if he had only had the presence of mind to pick up a rifle belonging to one of the enemy dead. (His own weapon was out of ammunition.) It was irrational for the veteran to weight the merits of his actions against an "option" that was not perceived during the battle and which first came to mind 20 years later. Hindsight bias is the mechanism that underlies this important thinking error, which sometimes results in severe self-flagellation (11).
Weighing the merits of actions taken against ideal or fantasy options which never existed.
Sometimes, trauma survivors evaluate or judge the goodness of their reasons for acting as they did "against non-existent fantasy choices that would have prevented the beating, avoided the rape or incest, or kept everyone safe and alive." . For example, soldiers in battle often find themselves faced with decisions to "kill or be killed." In such situations, courses of action which preserve everyone’s life do not exist. Nevertheless, some veterans weigh the merits of what they did against Superman-like actions that would have prevented violence or death. (8). They may give explanations such as "I should have thought of something. I don’t know what I could have done, but I should have thought of something."
Focusing only on "good" things that might have happened had an alternative action been taken.
Sometimes, trauma survivors glamorize an alternative course of action they contemplated but did not take when the trauma occurred, and they downplay or ignore likely negative consequences of the alternative course. For example, some adult incest survivors, who blame themselves for not disclosing their abuse as a child, dwell on the fact that the abuse might have stopped and the perpetrator given just punishment had they complained. At the same time, they may "forget" or disregard adverse consequences had they reported the abuse (e.g., that they themselves might have been blamed, hurt, or punished; that they would disrupt the family; that they would "betray" the offending family member).
Tendency to overlook "benefits" associated with actions taken.
Sometimes, trauma survivors maintain important values by their actions during trauma and fail to realize that, had they acted otherwise, these values would have been invalidated or violated to some degree. For example, some battered women who refuse to press charges against their partners confirm or validate values (held at the time) that they should "turn the other cheek" and could "change" their partner if they would just try harder.
Failure to compare available options in terms of their perceived probabilities of success before outcomes were known.
Sometimes, unselected courses of action, which seemed to be poor choices when the trauma occurred, are "recalled" as less likely to produce negative outcomes than actions taken. Instead of judging their reasons for acting as they did based on the quality or soundness of their decision making (before outcomes were known), some survivors judge their actions solely on the basis of the outcome. It is important for clients to know that even good decisions can (and occasionally will) turn out badly (because of laws of probability).
Failure to realize that (a) acting on speculative hunches rarely pays off and (b) occurrence of a low probability event is not evidence that one should have "bet" on this outcome before it occurred.
Trauma survivors occasionally say, in retrospect, that they should have acted on " hunches," "intuition," "premonitions," or "gut feelings"--which, if acted upon, might have prevented or avoided a tragic outcome. However, people do not ordinarily act on speculative hunches because they are typically "long shot" predictions, which experience has shown, tend not to be borne out. Furthermore, occurrence of a low probability outcome that was predicted by a hunch (e.g., "If I trade places with him, maybe something bad will happen") is not evidence that one should have acted on the hunch.
Thinking Errors That Contribute To Faulty Conclusions About Perceived Wrongdoing
Tendency to conclude wrongdoing on the basis of the outcome rather than on the basis of one's intentions (before the outcome was known).
Sometimes, trauma survivors conclude that they were guilty of wrongdoing, not because they behaved in ways inconsistent with their values, but because of an unfortunate (and unforeseeable) outcome. One client of mine was self-condemning and ashamed for asking a friend (when he was a child) to leave the beach and return with a fishing pole. (The boys had spotted a large school of fish.) On his way to get the pole, the friend fell off a rock jetty and drowned.
Failure to realize that strong emotional reactions are not under voluntary control (i.e., not a matter of choice or willpower).
Many combat veterans experience guilt about being afraid in battle (12), and many incest survivors experience guilt because they became physically aroused during the sexual abuse. However, strong emotional reactions are not intellectual decisions or moral choices. None of the veterans chose to be afraid, and had they been able to make an "intellectual decision" not to be afraid, they wouldn’t have been afraid. Similarly, children who are touched in certain ways by adults do not have "conscious control" over their autonomic nervous system.
Failure to recognize that, when all available options have negative outcomes, the least bad choice is a highly moral choice.
During traumatic events, individuals often confront situations in which all available courses of action have unfavorable consequences. Something bad is likely to happen whether or not a sexual assault victim fights back or does not resist, whether or not an incested child discloses the abuse or suffers in silence, or whether or not a soldier in battle shoots to kill or fires over the heads of the enemy. In all of these lose-lose situations, no unambiguously good choices are available, and the "least bad" choice reflects sound moral judgment by validating an individual’s most important values. For example, by shooting "to kill," the soldier may validate his values about the importance of his life and his buddies’ lives, and his beliefs about himself as a "patriotic and loyal" citizen.
A final thinking error, which contributes to all of the faulty conclusions is the belief that an emotional reaction to an idea provides evidence for the idea’s validity.
When an idea is associated with affect, the affect appears to give the idea a ring of "truth" or "untruth." For example, a survivor might say, "Intellectually, I agree with you; but, I still feel responsible" or "Deep down in my heart, I still feel that what I did was wrong." The client might be told that "I feel responsible is not an emotion. What do you think you were responsible for causing?" A battered woman was tempted to reconcile with a boyfriend (who had almost killed her on several occasions) because she "felt sorry" for him. The woman was reminded that "how you feel when you think about staying away or reconciling is not evidence that it is in your best interests to stay away or go back."
Cognitive Therapy For Trauma-Related Guilt
The goal of cognitive therapy for trauma-related guilt (CT-TRG) is to help clients achieve an objective and undistorted appraisal of their role in trauma. CT-TRG has three phases: (a) assessment, (b) debriefing or imaginal exposure exercises, and (c) formal CT-TRG, which involves separate procedures for correcting thinking errors that lead to faulty conclusions associated with guilt (2). The thinking errors identified above are addressed in the context of four separate, semi-structured procedures for teaching clients to distinguish what they knew "then" from what they know "now," and for reappraising perceptions of justification, responsibility, and wrongdoing (in light of beliefs held and knowledge possessed when the trauma occurred). Space limitations here preclude an elaboration of the phases and procedures of CT-TRG, which are described in detail elsewhere (2,8,13). Clinicians interested in implementing CT-TRG are encouraged to examine these other sources.
References
1. Frazier, P. A., & Schauben, L. (1994). Causal attributions and recovery from rape and other stressful life events. (1994). Journal of Social and Clinical Psychology, 13, 1-14.
2. Kubany, E. S., & Manke, F. P. (1995). Cognitive therapy for trauma-related guilt: Conceptual bases and treatment outlines. Cognitive and Behavioral Practice 2, 23-61.
3. Resick, P. A. (1993). Cognitive processing for rape victims. Newbury Park: Sage.
4. Kubany, E. S., Abueg, F. R., Brennan, J. M., Owens, J. A, Kaplan, A., & Watson S. (1995). Initial examination of a multidimensional model of trauma-related guilt: Applications to combat veterans and battered women. Journal of Psychopathology and Behavioral Assessment, 17, 353-376.
5. Kubany, E. S., Haynes, S. N., Abueg, F. R., Manke, F. P., Brennan, J. M., & Stahura, C. (1996). Development and validation of the Trauma-Related Guilt Inventory (TRGI). Psychological Assessment (1996) 8, 428-444.
6. Miller, D., & Porter, C. (1983). Self-blame in victims of violence. Journal of Social Issues, 39, 139-152.
7. Kubany, E. S. (1994). A cognitive model of guilt typology in combat-related PTSD. Journal of Traumatic Stress, 7, 3-19
8. Kubany, E. S. (1996). Application of Cognitive Therapy for Trauma-Related Guilt (CT-TRG) with a Vietnam veteran troubled by multiple sources of guilt. Manuscript submitted for publication.
9. Hawkins, S. A., & Hastie, R. (1990). Hindsight: Biased judgments of past events after outcomes are known. Psychological Bulletin, 107, 311-327.
10. Rando, T. A. (Ed.). (1986). Parental loss of a child. Champaign, IL: Research Press.
11. Pitman, R. K., Altman, B., Greenwald, E., Longpre, R. E., Macklin, M. L., Poire', R. E., & Steketee, G. S. (1991). Psychiatric complications during flooding therapy for posttraumatic stress disorder. Journal of Clinical Psychiatry, 52, 17-20.
12. Kubany, E. S., Abueg, F. R., Kilauano, W., Manke, F. P., & Kaplan, A. (1997). Development and validation of the Sources of Trauma-Related Guilt Survey--War-Zone Version. Journal of Traumatic Stress (1997, 8, 235-257.).
13. Kubany, E. S. (1996). Cognitive Therapy for Trauma-Related Guilt. Audiotape distributed by the National Center for PTSD, Education Division, Palo Alto/Menlo Park, CA.
Edward S. Kubany is a clinical psychologist and research health scientist at the Pacific Islands Division of the National Center for PTSD, in Honolulu, Hawaill. He is also Associate Professor in Clinical Psychology at the University of Hawaii. Dr Kubany’s interests are in psychometric scale development and development of psychological interventions, with an emphasis on the assessment and treatment of PTSD and trauma-related guilt and depression, across trauma populations.
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