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Home , Guilt (emotion), Remorse

Vol. I., No. 1 April 2019

Building Resilience from Survivor After a Traumatic Event Veronica Powell, PhD Measures4Success, LLC

Monique Swift, PsyD Swift Solutions Consulting Services, LLC

Please address correspondence to: Veronica Powell, PhD, LPC, Measures4Success, LLC, 1629 K St NW Suite 300 Washington, DC 20006 ([email protected]) Monique Swift, PsyD, LPC, Swift Solutions Consultant Services, LLC, 362 Albermarle St., Rahway, NJ 07065 ([email protected])

The authors have no conflicts of to declare as it pertains to this article.

Abstract: Not a year goes by without media coverage of causalities involving mass violence or natural disasters. Those affected directly or indirectly are left to pick up the pieces and establish a “new norm” for navigating the that was lost pre-tragedy. Those who physically survived the trauma of mass casualties are challenged to reconcile various emotional reactions such as guilt from the tragedy. The of guilt take on a transformative quality, moving from healthy guilt to unhealthy guilt, such as survivor guilt. With guilt itself being a powerful , those plagued by the grips of survivor guilt may be limited in their ability to recognize the role of resiliency to assist in their recovery and healing from the trauma. Additionally, practitioners may be challenged to assist trauma survivors with complex guilt reactions. This paper examines the etiology, symptoms, and intervention strategies for survivor guilt and its impact on trauma survivors and provides strategies to assist trauma survivors in harnessing the power of resilience to move through the barriers of survivor guilt post-tragedy.

Keywords: guilt, survivor guilt, PTSD, , protective factors, resilience

The experience of guilt after a traumatic ), decreased self-esteem, or limited event is not a new phenomenon. In general, social support (Good Therapy, 2018). These guilt represents a form of judgment that may be factors are noted to increase the trauma based on one’s system, such as survivor’s susceptibility to developing survivor from something that is believed to be bad, guilt. wrong, or a biblical (Fink, 2016). The destructive impact of a traumatic Unfortunately, the unprecedented rise of experience on a trauma survivor depends on natural disasters and mass violence has created factors such as characteristics of the individual, a shift in how survivors of a traumatic the type of event(s), developmental processes, event process the emotion of guilt. Although a the significance of the trauma, and traumatic event may people differently, sociocultural factors (SAMSHA, 2014). For some trauma survivors may display increased example, a CNN interview of a trauma survivor vulnerability to the impact of guilt, whereas from the 2017 Las Vegas massacre described others may exhibit more resilient responses to the guilt of surviving the massacre “unscathed” the trauma. An individual’s vulnerability to and not knowing if they “Did enough?” or if guilt may be related to factors such as a history they “Helped enough people?” (Ellefson, of trauma, mood related disorders, (i.e., 2017). The survivor presented a classic case of

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Building Resilience from Survivor Guilt After a Traumatic Event what is known as survivor guilt. I too [VP] can instinctual survival drives and in a attest to the experience of survivor guilt. When prosocial direction. Valent further noted that I was 14 years old (1984 Easter weekend), a guilt is one of three moral judgments, with the tornado in my rural Mississippi community other two being (e.g., judgment of an killed a family who lived approximately one individual’s worth) and justice (e.g., judgment mile from my home. I reflect on my own of fairness). experience of survivor guilt after surviving the Fundamentally, guilt has prosocial storm. I was left with many questions such as attributes in that it judges an individual’s “How come my family didn’t die from the actions as good or bad and can strengthen storm?” “How did the tornado sideswipe my interpersonal relationships (Valent, 1998; house (without destroying it) and then Baumeister, 1997). However, for those who miraculously go back in the air, only to touch have experienced a traumatic event there is a down and destroy the house and the family potential for the individual to feel excessive or down the road from us?” “Why them and not irrational guilt over surviving the trauma. us?” “How did we escape and not them?” Kubany and Manke (1995) identified four “What could we have done to warn the family cognitive factors of guilt related to survivors of down the road?” “What was my purpose for traumatic events as identified in traumatized living?” (Powell, 2019). individuals: (1) a violation personal standard This article expands the general related to right or wrong; (2) perceived of survivor guilt and its ownership/responsibility or preventability of differentiating factors from what represents a the event; (3) perceived lack of justification for healthy response to guilt versus unhealthy guilt. acting; and (4) false beliefs regarding pre- Further examination of survivor guilt includes outcome knowledge or hindsight bias. Guilt a review of the literature on (a) its etiology, that is associated with an individual surviving symptoms, and intervention strategies; (b) the or being uninjured in circumstances whereby impact on trauma survivors; (c) postvention another person died or was physically or treatment strategies; and how the power of psychologically injured is known as survivor resilience is leveraged to move through the guilt (Hutson, Hall & Pack, 2015). barriers of survivor guilt post tragedy. A contextualization of guilt is presented as a Etiology, Symptoms, and Intervention baseline to understanding survivor guilt. for Survivor Guilt Survivor guilt as an unintended Contextualizing Guilt consequence of a traumatic experience has A review of the literature identifies several been recognized as a shared phenomenon by definitions associated with the concept of guilt. trauma survivors. For example, Neiderland Guilt is generally defined as a fact or state of (1961) introduced the concept of survivor guilt having committed an offense, crime, violation based on his work with Holocaust patients. or wrong that goes against a moral standard or Through his observations, Neiderland penal law (as cited in Elliot, 2018). It is further described a psychological state that was defined as a cognitive or emotional experience common among survivors from World War II occurring when an individual or concentration camps. He noted that survivors realizes that they have compromised their own displayed of intense guilt for surviving standard of conduct or violated a universal loved ones who were killed in the concentration moral standard and feel significantly camps and would behave as if they were dead responsible for the violation. Tilghman- themselves (O’Connor, Berry, Weiss, Bush, & Osborne, Cole, and Felton (2010) expand the Sampson, 1997). The concept of survivor guilt definition of guilt as representing “moral was further expanded to include all trauma- transgressions (real or imagined) in which related events, be they natural or manmade. people believe that their action (or inaction) According to Modell (1971), survivor guilt contributed to negative outcomes” (p. 546). can include more subtle forms such as Valent (1998, 2000), described guilt as an inhibiting oneself from success, engaging in internal moral judgment that aims to modify self-destructive behavior, or over-identifying ______

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Building Resilience from Survivor Guilt After a Traumatic Event

with one’s . Valent (2000) identified trauma-related symptoms. Furthermore, the following eight survival behaviors that are symptoms of survivor guilt are often related to associated with survivor guilt: those of and depression. 1. Rescue/caretaking mode involves agonizing over Symptoms experienced may range from guilt due to neglectfulness and self-concerning mild to severe, and may impact physical being, behavior that caused harm, suffering, or death to thoughts, feelings, and behaviors. A few others, particularly those for whom they bore examples of symptoms are presented in Table responsibility. Individuals operating in 1 (adapted from Weaver, 2011, p. 15; rescue/caretaking mode will themselves for E4Health, 2012). not saving those for whom they felt a sense of The noted symptoms experienced by a responsibility. trauma survivor indicate that intervention is 2. Attachment consist of guilt that is experienced as warranted to mitigate the long-term negative bad, sinful, or disobedient. The individual believes consequences of psychological trauma. When that they are the cause of the catastrophe and by working with trauma survivors, it is important abandoning the situation, must be punished for to validate their experience of the trauma by their badness. acknowledging the normalcy of their response 3. achievement represents guilt that is or reaction to an abnormal situation. There are associated with failure, feelings of inadequacy, or several crisis intervention models designed to incompetence. Individuals may also view assist trauma survivors in navigating their path themselves as being stupid, clumsy, or lazy. to healing from the trauma. For example, 4. Goal surrender occurs when an individual feels Mitchell’s (1983) Critical guilty over giving up, giving in, despair, or Debriefing (CISD) model is a precise, 7-phase, attempting suicide. small group, supportive crisis intervention 5. Fight is described as a self-defense or defense of process designed to facilitate reduction in others mechanism. However, when it involves distress, restore group cohesion and unit mistaken causing of damage or death, one’s guilt performance. CISD is a psycho-educational reaction invokes horror or dismay. Valent notes process and is not considered to be a form of that the individual may feel like a wicked psychological therapy. Psychological first aid murderer. is an evidence-informed model that is 6. Flight evokes guilt from having left others behind, employed in disaster response assisting those evading responsibility, acting cowardly, lacking impacted in the hours and early days following moral character, or engaging in bystander . an emergency, disaster, or terroristic act 7. Competition consists of priority guilt, whereby (Uhernik & Husson, 2009). The authors note there is a belief that people undeservedly survived that psychological first aid has emerged as a at the expense of others and that really, they should preferred response for disaster emergencies. have died instead of the ones who perished. After the initial phase of trauma response 8. Cooperation evokes guilt whereby there is interventions, can be turned to a sense of cheating, lying, exploitation or hurt of postvention strategies. partners. Survivors of a traumatic event who Postvention Strategies for Survivor display survivor guilt are at risk of developing what Lee, Scragg, and Turner (2001) described Guilt as guilt-based post-traumatic stress disorder Postvention is a concept that originated (PTSD). The researchers noted that the from the field of suicidology and was first personalization of the traumatic event by the coined by Shneidman (1981). The basic individual may significantly influence the premise of postvention is a strategy that occurs development of PTSD. For example, Bub and after the traumatic incident and offers crisis Lommen (2017) noted that pre-trauma schemas intervention, support, and assistance for those that an individual had of themselves activate or impacted by trauma related injury. Postvention confirm underlying guilt-associated beliefs principles are transferable to non-suicide about the self. The increased vulnerability to related traumas. When working with trauma guilt-based PTSD consequently yields various survivors’ post-tragedy, emphasis is placed

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Table 1. Symptoms related to survivor guilt (Adapted with permission) Thoughts Feelings Physical/ Behavioral Recurring or Numbness, withdrawn, or Overprotective of your nightmares about the disaster disconnected and your family's safety

Reconstructing the events and anxiety when from others surrounding the disaster in your reminded of the disaster such as mind, in an effort to make it come sights, sounds, and smells out differently Recurring dreams or Feeling depressed Hypervigilant and easily nightmares about the disaster startled Reconstructing the events outburst or intense Challenges getting to surrounding the disaster in your sleep or staying asleep mind, in an effort to make it come out differently Difficulty concentrating or or hopelessness Avoidance of activities, remembering things about the future people, places or things that are reminders of the disaster Poor attention span Feelings of Increased conflict with family members, significant other, friends, etc. Questioning one's spiritual Feelings of shock/startled Excessively busy to avoid or religious beliefs thinking about the disaster and what has happened to you Ruminating thoughts or Feelings of Increased alcohol memories of the disaster, or of consumption or illicit drug use individuals who died in the disaster Suicidal thinking Feelings of guilt spells for no apparent reason Delay in processing Feeling lost Nausea, upset stomach, or thinking diarrhea, chills, sweating

Difficulty in problem solving Feeling abandoned Tremors/ poor coordination. Increased blood pressure / headaches Disorientation (particularly to Feelings of irritability Rapid heartbeat, time) breathing, muscle aches and cramps Challenges in naming Feelings of isolation. common objects on (a) processes that facilitate the grief or adjustment reduction for further traumatization (Higher process; (b) stabilization of the trauma survivor Education Mental Health Alliance [HEMA], 2014). environment; (c) risk reduction of negative behaviors Further for postvention efforts include the such those associated with survivor guilt; and (d) risk following noted in Table 2: ______

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Building resilience from survivor Table 2. Postvention Goals (HEMA, 2014) guilt Unbeknownst to most trauma survivors is their resilient ability to navigate through Postvention Goals traumatic experiences. A basic definition of resilience is an individual’s ability to develop a. To provide assistance to trauma survivors psychological and emotional skills, as well as impacted by the traumatic event and its the ability to use familial, social, and other associated negative responses by reducing external protective support to navigate through the intensity of the individual's or group's emotional, mental, physical and behavioral stressful life events or experiences (Suri, 2018). reactions to the trauma; Resiliency also represents the ability to adapt and overcome adversity. In building resiliency b. To facilitate restoration of some semblance of order and routine by assisting trauma from survivor guilt through therapeutic survivors to return to their pre-trauma level of intervention, trauma survivors can experience functioning; post-traumatic growth, which involves positive c. To prevent or minimize risk of further trauma changes that individuals experience after related injury; challenges encountered with a major life crisis d. To create and provide a safe space where or traumatic event (Lucario, 2018). Protective trauma survivors can process what factors, which refers to characteristics that happened, express difficult emotions and understand the impact of the trauma event; prevent or reduce vulnerability for the development of maladaptive behavior or e. To avoid memorializing grief and its associated emotions that prevent disorders, may contribute to post-traumatic remembrance of life prior to the traumatic growth as well. Additionally, protective factors event; and include strengths or assets that assist f. To educate trauma survivors on how to utilize individuals to maintain mental health well- protective factors to build resiliency from the being and resilience at the individual level and impact of trauma related injury. other supportive resources (i.e., family, peers, school/work, and community) (MindMatter, 2008). For example, protective factors that Postvention strategies for managing promote resiliency from survivor guilt may survivor guilt allow trauma survivors the include one’s ability to (1) regulate emotions; opportunity to leverage resources designed to (2) demonstrate effective coping and problem- promote and foster healing post-tragedy. solving skills; (3) display towards Valent (2000) noted that protocols for the life; and (4) have a positive attitude in seeking treatment of survivor guilt involve assisting and receiving help. trauma survivors in (1) delineating perceptions Other resiliency strategies to curtail the of responsibility as it related to what could impact of survivor guilt are teaching trauma feasibly be done under the presented survivors self-care, including how to recognize circumstances; (2) mitigating behaviors that contribute to self-. Some fatigue; and (3) engagement of early debriefing examples of self-care include regular exercise, to ameliorate survivor guilt. Through fact- healthy nutritional and sleep hygiene, finding efforts, individuals working with engagement in physical care and grooming, and trauma survivors can facilitate movement rest and (GoodTherapy, 2018). A toward accepting that their best was done and solid support system is another critical aspect using the strength of resilience to navigate the of building resiliency from survivor guilt. adversity. Most often trauma survivors are Support networks that foster trusting and unable to immediately recognize or supportive relationships are beneficial for acknowledge their resilient ability along with trauma survivors. Through these relationships, protective factors as a source of strength in trauma survivors are able to (1) vocalize their reconciling their response to guilt. experiences of living with the guilt and connect with those who shared the experience; (2) participate in support groups; (3) build a ______

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Building Resilience from Survivor Guilt After a Traumatic Event community that represents their new norm Bub, K., & Lommen, M. J. J. (2017). The role of guilt post-trauma; and (4) experience a sense of in posttraumatic stress disorder. European validation in being heard and understood by a Journal of Psychotraumatology, 8, 2 – 9. support system that cares. Ultimately through Center for Substance Abuse Treatment. (2014). each intervention the trauma survivor is put Trauma-informed care in behavioral health closer to the path of reconciling their own grief services. Rockville (MD): Substance Abuse and of a life that was (pre-trauma) to a life of what Mental Health Services Administration (US); it has become (post-trauma). (Treatment Improvement Protocol (TIP) Series, Conclusion No. 57.) Chapter 3, Understanding the Impact of Survivor guilt is a complex phenomenon Trauma. Retrieved from: that is rooted in trauma-related experiences. https://www.ncbi.nlm.nih.gov/books/NBK2072 This article presented the concepts of survivor 01/pdf/Bookshelf_NBK207201.pdf. guilt that included understanding its etiology, E4Healthinc.com. (2012). Dealing with survivor guilt. associated symptoms, and intervention Retrieved from strategies. An evaluation of the consequences http://prp.jasonfoundation.com/files/2012/10/De of survivor guilt revealed trauma survivors’ aling-with-Survivor-Guilt.pdf. vulnerability to mood and anxiety disorders, including guilt-based PTSD. A review of the Ellefson, L. (2017). Las Vegas survivor describes literature provided a broader context of the guilt: 'Did I do enough?' Retrieved from many variables associated with survivor guilt https://www.cnn.com/2017/10/03/us/brian- that influence the recovery and healing of claypool-guilt-new-day-cnntv/index.html. trauma survivors. Elliot, B. (2018). Understanding guilt, shame, and The author’s own experience of survivor moral injury in veteran patients. Med-Surg guilt was revealing in that many of the Matters, 27(6), 10-12. interventions suggested in this writing were not offered or available to trauma survivors in a Fink, G. (2016). Stress: Concepts, Cognition, rural Mississippi town in the mid-1980s. This Emotion, and Behavior: Handbook in Stress review shows the importance of trauma Series, Volume 1. Cambridge, MA; Elsevier. survivors having unrestricted access to GoodTherapy.org. (2018). Survivor guilt. Retrieved treatment services, resources, and support from https://www.goodtherapy.org/ systems. Furthermore, exploration of the role of blog/psychpedia/survivor-guilt. protective factors and the power of resiliency reveals how a trauma survivor could move Higher Education Mental Health Alliance (HEMA). towards post-traumatic growth, and, ultimately, (2014). Postvention: A guide for response to healing from their grief. Since healing from a suicide on college campuses. Retrieved from trauma-related injury is a lifelong process, https://www.sprc.org/sites/default/files/resource strategies for promoting positive, healthy self- -program/Hemha-postvention-guide.pdf. care was presented. Trauma survivors who Hutson, S. P., Hall, J. M., & Pack, F. L. (2015). have been plagued with survivor guilt no longer Survivor guilt: analyzing the concept and its have to be silent to its debilitating effects. The contexts. Advances in Nursing Science, 38(1), upcoming 2019 conference of the International 20-33. Critical Incident Stress Foundation (ICISF) is one of many resources that are giving survivor Lee, D. A., Scragg, P., & Turner, S. (2001). The role guilt a voice and pathway to healing. of shame and guilt in traumatic events: A clinical model of shame-based and guilt-based PTSD. References British Journal of Medical Psychology, 74, 451– Baumeister, R. F. (1997). Evil: Inside Human Violence 466. and Cruelty. New York: Freeman. Lucario, L. H. (2018). Healing from complex trauma Baumeister, R. F., Stillwell, A. M., & Heatherton, T. and PTSD. Retrieved from F. (1994). Guilt: An interpersonal approach. https://www.healingfromcomplextraumaandptsd Psychological Bulletin, 115, 243–267. .com/building-resilience.

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MindMatters. (n.d.). Protective and risk factors. R. Walz, J. C. Bleuer, & R. K. Yep (Eds.), Retrieved from Compelling counseling interventions: DISTAS https://www.mindmatters.edu.au/docs/default- 2009 (pp. 271-280). Alexandria, VA: American source/learning-module- Counseling Association. documents/j4633_mm_module1-3- Valent, P. (1998). Series in trauma and loss. From protectiveriskfactors_v2.pdf. survival to fulfillment: A framework for the life- Mitchell, J. T. (1983, January). When disaster trauma dialectic. Philadelphia, PA: strikes...The critical incident stress debriefing Brunner/Mazel. process. Journal of Emergency Services, 8(1), Valent, P. (2000). Survivor guilt. In G. Fink, 36-39. Encyclopedia of Stress, Volume 3. New York, Modell, A.H. (1971). The origin of certain forms of NY: Academic Press. Retrieved from pre-oedipal guilt and the implications for a http://www.paulvalent.com/wp- psychoanalytic theory of affects. International content/uploads/2013/02/disasters_consequence Journal of Psychoanalysis, 52, 337–346. s_06.pdf. Neiderland, W.G. (1961). The problem of the Weaver, J. D. (2011). Assisting in the aftermath of survivor. Journal of Hillside Hospital, 10, 233– disasters (and other life crisis). Retrieved from 247. https://c.ymcdn.com/sites/www.naswma.org/res ource/resmgr/imported/FCE_2011.12_%20Afte O’Connor, L. E., Berry, J. W., Weiss, J., Bush, M., & rmathofDisasters.pdf. Sampson, H. (1997). Interpersonal guilt: The development of a new measure. Journal of Clinical Psychology, 53(1), 73-89.

Powell, V. (2019). Self-account of surviving a tornado. Unpublished manuscript, Measures4Success, LLC. Shneidman, E. S. (1981). The psychological autopsy. Suicide and Life-Threatening Behavior, 11, 325– 340. Substance Abuse and Mental Health Services Administration (SAMSHA). (2014). Trauma- Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. HHS Publication No. (SMA) 13-4801. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from https://www.ncbi.nlm.nih.gov/books/ NBK207201/pdf/Bookshelf_NBK207201.pdf. Suri, R. (2018). Promoting resilience in the traumatized. Retrieved from https://strengthtoheal.org/promoting-resilience- in-the-traumatized/. Tilghman-Osborne, C., Cole, A. D., & Felton, J. W. (2010). Definition and measurement of guilt: Implications for clinical research and practice. Clinical Psychology Review, 30, 536–546.

Uhernik, J. A., & Husson, M. A. (2009). Psychological first aid: An evidence informed approach for acute disaster behavioral health response. In G. ______

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