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Effectiveness of treatments for symptoms of post-trauma related guilt, shame and anger in military and civilian populations: a systematic review
  1. Danai Serfioti1,2,3,
  2. D Murphy4,
  3. N Greenberg5 and
  4. V Williamson2,6
  1. 1University of Derby, Derby, UK
  2. 2KCMHR, Institute of Psychiatry Psychology and Neuroscience Department of Basic and Clinical Neuroscience, London, UK
  3. 3Nottingham Trent University, Nottingham, UK
  4. 4Combat Stress, Leatherhead, UK
  5. 5Academic Department for Military Mental Health, King's College London, London, UK
  6. 6University of Oxford, Oxford, UK
  1. Correspondence to Dr V Williamson, KCMHR, Institute of Psychiatry Psychology and Neuroscience Department of Basic and Clinical Neuroscience, London SE5 8AF, UK; victoria.williamson{at}


Introduction Individuals who have been exposed to a traumatic event can develop profound feelings of guilt, shame and anger. Yet, studies of treatments for post-traumatic stress disorder (PTSD) have largely investigated changes in PTSD symptoms relating to a sense of ongoing fear or threat and the effectiveness of such treatments for post-trauma related guilt, shame or anger symptom reduction is comparatively not well understood.

Methods This review systematically examined the effectiveness of existing treatment approaches for three symptoms associated with exposure to traumatic events: guilt, shame and anger. Studies included had to be published after 2010 with a sample size of n=50 or greater to ensure stable treatment outcome estimates.

Results 15 studies were included, consisting of both civilian and (ex-) military population samples exposed to a wide range of traumatic events (eg, combat-related, sexual abuse). Findings indicated a moderate strength of evidence that both cognitive-based and exposure-based treatments are similarly effective in reducing symptoms. Cognitive-based treatments were found to effectively reduce post-trauma related guilt and anger, while exposure-based treatments appeared effective for post-trauma related guilt, shame and anger.

Conclusions The findings suggest the importance of confronting and discussing the traumatic event during therapy, rather than using less directive treatments (eg, supportive counselling).Nonetheless, while these results are promising, firm conclusions regarding the comparative effectiveness and long-term impact of these treatments could not be drawn due to insufficient evidence. Further empirical research is needed to examine populations exposed to traumatic events and investigate which treatment approaches (or combination thereof) are more effective in the long-term.

  • Clinical audit

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  • Contributors All authors contributed to study design, data extraction and analysis and manuscript writing. All authors read and approved the manuscript before submission. DS is guarantor.

  • Funding This study was funded by Forces in Mind Trust.

  • Disclaimer DM is a trustee of Forces in Mind Trust. Forces in Mind Trust did not influence the design, results or recommendations of this manuscript.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.