Guilt Assessment

Assessment is an integral part of the CT-TRG model. We use a structured interview and specially designed questionnaires (1) to identify idiosyncratic sources of trauma-related guilt, (2) to assess clients' faulty thinking patterns, and (3) to evaluate treatment efficacy.

Structured Guilt Assessment Interview

We use a structured interview to identify important issues across five domains of guilt (Kubany & Manke, 1995). This interview (which also includes follow-up probes) consists of five core questions about the trauma that ask whether respondents feel guilty about (1) anything they did, (2) anything they did not do, (3) feelings they had, (4) feelings they did not have, and (5) thoughts or beliefs they had. For example, clients may be asked, "Do you feel guilty about anything you did related to the trauma? . . . Tell me about that."

TABLE 11.1. Thinking Errors That Lead to Faulty Conclusions and Trauma-Related Guilt

Thinking error that contributes to faulty conclusions about knowledge possessed before outcome was known (regarding the foreseeability and preventability of negative outcomes)

HB Hindsight-biased thinking

Thinking errors that contribute to faulty conclusions about justification or goodness of reasons for acting as one did

J#1: Weighing the merits of actions taken against idealized actions that did not exist

J#2: Weighing the merits of actions taken against options that only came to mind later

J#3: Focusing only on "good" things that might have happened had an alternative action been taken

J#4: Tendency to overlook "benefits" associated with actions taken

J#5: Failure to compare available options in terms of their perceived probabilities of success before outcomes were known

J#6: 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

J#7: Failure to recognize that different decision-making "rules" apply when time is precious than in situations that allow extended contemplation of options

J#8: Failure to recognize that in heightened states of negative arousal, one's ability to think clearly and make logical decisions is impaired

Thinking errors that contribute to faulty conclusions about degree of responsibility for causing negative outcomes

R#1: Hindsight-biased thinking

R#2: Obliviousness to totality of forces that cause traumatic events

R#3: Equating a belief that one could have done something to prevent the traumatic event with a belief that one caused the event

R#4: Confusion between responsibility as accountability (e.g., "my job")

and responsibility as having the power to cause or control outcomes

R#5: Existential beliefs about accountability and the need to accept the consequences of one's actions—which fail to take into account the causal power of situational forces

Thinking errors that contribute to faulty conclusions about wrongdoing or violation of values

W#1: Tendency to conclude wrongdoing on the basis of outcome rather than on the basis of one's intentions before the outcome was known

W#2: Failure to realize that strong emotional reactions are not under voluntary control (i.e., not a matter of choice or willpower)

W#3 The tendency to "inflate" the seriousness of a minor moral violation— from "misdemeanor" to "felony" status—when the minor violation leads unforeseeably to a traumatic outcome

W#4: Failure to recognize that when all available options have negative outcomes, the least bad option is a sound and moral choice

Thinking error that contributes to all of the faulty conclusions

ALL1: Belief that an emotional reaction to an idea provides evidence for the idea's validity—also called emotional reasoning

Attitudes About Guilt Survey

The Attitudes About Guilt Survey (AAGS) is a brief questionnaire that is used to assess the presence and magnitude of guilt components with regard to highly specific guilt issues (Kubany et al., 1995; Kubany & Manke, 1995; Kubany et al., 2004b). The AAGS, which is reproduced at the end of this chapter in Appendix 11.1, assesses the magnitudes of four guilt-related beliefs and the magnitudes of distress and guilt related to specified guilt issues. Clients are asked to fill out a separate AAGS for each guilt issue targeted for intervention, and before each guilt issue is analyzed, they are asked to explain their responses to the guilt-cognition items (items 1-4). In addition to its value for initial assessment, the AAGS can be readministered as therapy proceeds to assess progress, lack of progress, or "slippage" (i.e., reversion to faulty logic that seemed to have been corrected) and the need for additional work.

Trauma-Related Guilt Inventory

The TRGI (Kubany et al., 1996; Western Psychological Services, 2004) was constructed to assess guilt and cognitive and emotional aspects of guilt associated with specified traumatic events (e.g., combat, physical or sexual abuse). The TRGI includes three scales and three subscales. The scales include a Global Guilt Scale, a Distress Scale, and a Guilt Cognitions Scale, which includes items that comprise the three subscales—Hindsight-Bias/ Responsibility, Wrongdoing, and Lack of Justification. The TRGI is meant to be used as a molar measure of trauma-related guilt (e.g., combat-related guilt, incest-related guilt) rather than as a measure of more specific guilt issues occurring within the context of the trauma (e.g., guilt about having been afraid or trading places with someone who got killed). The TRGI, which assesses 22 specific trauma-related beliefs, may have considerable utility as a treatment-outcome measure in CT-TRG and other cognitive-behavioral interventions aimed at modifying trauma survivors' beliefs about their role in trauma.

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