A cognitive behavioural therapy (CBT) approach for working with strong feelings of guilt after traumatic events

Abstract This article outlines a cognitive behavioural therapy (CBT) approach to treating feelings of guilt and aims to be a practical ‘how to’ guide for therapists. The therapeutic techniques were developed in the context of working with clients with a diagnosis of post-traumatic stress disorder (PTSD); however, the ideas can also be used when working with clients who do not meet a diagnosis of PTSD but have experienced trauma or adversity and feel guilty. The techniques in this article are therefore widely applicable: to veterans, refugees, survivors of abuse, the bereaved, and healthcare professionals affected by COVID-19, amongst others. We consider how to assess and formulate feelings of guilt and suggest multiple cognitive and imagery strategies which can be used to reduce feelings of guilt. When working with clients with a diagnosis of PTSD, it is important to establish whether the guilt was first experienced during the traumatic event (peri-traumatically) or after the traumatic event (post-traumatically). If the guilt is peri-traumatic, following cognitive work, this new information may then need to be integrated into the traumatic memory during reliving. Key learning aims (1) To understand why feelings of guilt may arise following experiences of trauma or adversity. (2) To be able to assess and formulate feelings of guilt. (3) To be able to choose an appropriate cognitive technique, based on the reason for the feeling of guilt/responsibility, and work through this with a client. (4) To be able to use imagery techniques to support cognitive interventions with feelings of guilt.