Changes in guilt cognitions mediate the effect of trauma-informed guilt reduction therapy on PTSD and depression outcomes

Objective

Trauma-informed guilt reduction therapy (TrIGR), a six-session cognitive behavioral therapy targeting trauma-related guilt and distress, reduces guilt and symptoms of posttraumatic stress disorder (PTSD) and depression, yet little is known regarding how and why TrIGR may be effective.

Method

This study examined treatment-related changes in avoidant coping and trauma-related guilt cognitions as possible mediators of treatment effects on PTSD and depression outcomes at 3- and 6-month follow-up. Data were from a randomized controlled trial for treatment of trauma-related guilt comparing TrIGR and supportive care therapy among 145 post-9/11 US veterans (M_age = 39.2 [8.1], 93.8% male).

Results

At pretreatment, most (86%) met PTSD criteria. Intent to treat analyses using parallel mediation models indicated changes in guilt cognitions, but not avoidant coping, mediated the effect of TrIGR on reducing PTSD severity at 3-month (a × b = −0.15, p < 0.01, 95% CI: [−0.24 to −0.06], p = 0.001) and 6-month (a × b = −0.17, 95% CI: [−0.26 to −0.07], p = 0.001) follow-up. Similarly, changes in guilt cognitions, but not avoidant coping, mediated the effect of TrIGR on reducing depression severity at 3-month (a × b = −0.10, 95% CI: [−0.18 to −0.02], p = 0.02) and 6-month (a × b = −0.11, 95% CI: [−0.20 to −0.03], p = 0.01) follow-up.

Conclusions

Compared to guilt cognitions, changes in avoidant coping were less integral to downstream PTSD and depression symptom reduction. Guilt cognition change may be a salient active ingredient of PTSD and depression treatment for those with trauma-related guilt and a key therapy element to which providers should be attuned.