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Section 20
Survivor Guilt and Self-Blame

Question 20 | Test | Table of Contents

Survivor guilt is so central to PTSD that it used to be considered one of the formal criteria for diagnosing the disorder. It was removed from the formal criteria, not because it isn’t prevalent among trauma survivors, but because it was not seen as being essential to the numbing­ reexperiencing cycle of PTSD. Yet, in my many years of work with traumatized veterans, I have yet to meet a veteran who, while grateful to be alive, is not also overflowing with guilt at having lived while others of his comrades died.

If your client is a combat veteran, he can have survivor guilt even if he does not feel responsible in any way for the deaths of your fellow soldiers. However, his survivor guilt will be especially strong if he feels some act of cowardice, aggression, or incompetence on his part con­tributed to the death of one of his fellow combatants. According to veteran and psychologist Tom Williams (1987), survivors of war need to learn that "it is okay to feel sad about someone’s having died in a traumatic situation, but it is not rational or appropriate to feel total responsibility for that person’s death. A war veteran, failing to comprehend that, will blame himself for the death of a friend, failing to realize that the enemy was the killer. The war should be blamed, not those who lived through it."

The exercise that follows will help your client pinpoint and resolve any feelings of self-blame and guilt that he has.

Client Exercise: Reducing Self-Blame and Guilt Feelings
As difficult and painful as it may be, try to make a list of some of the actions or inactions about which you now, in peacetime, experience guilt or remorse or about which you have second thoughts. Then complete the following steps for each of those events:

1. Formulate as complete a picture of the situation as possible, taking into account
• the physical condition of your body. For example, were you tired, hungry, or sick? • the temperature and terrain of the location. • the physical condition and morale of your comrades. • any significant events that preceded the event, for instance, a buddy’s death, an atrocity having been committed, an officer getting fragged, an attack of friendly fire, combat boredom, a letter from home with upsetting news, a lack of contact with family members, and so on.

2. For each situation, indicate what you cannot remember, areas where your memory is incomplete or confused, and information you did not have at the time and perhaps still do not have. For example, during the combat situation, were you able to see how many enemy troops were against you or other important features of the situation, such as your own wounds or the wounds of a comrade? If the situation involved individuals in civilian clothing, was there a way to tell if they were armed or not? What details of the situation might you have missed because you were preoccupied with the task at hand or with survival issues?

3. Given the circumstances you have described above, what were your real choices? List the choices in as much detail as possible.

4. For each choice you listed in step 3, write down what you think might have happened as a result of following that particular course of action.

5. In retrospect, would any of the choices you listed in step 3 have been preferable to you than what you did at the time? If so, why?

6. If you feel you made the best choice possible and you are still blaming yourself for your choice, ask yourself why. Is your self-blame due to the feedback of your comrades, commanding officers, family members, friends, or others?

7. If you feel you didn’t make the best choice and should have chosen differently, can you identify your reasons for choosing the way you did? This question is not meant to be accusatory, but to have you search out the combat-related stresses that led you to make a decision about which today you suffer some guilt or moral confusion.

For example, have you considered whether you were hungry, tired, or urged by others to make the choice you did? Were you seeking revenge for the death of a friend or some horror you had witnessed? Were you expressing rebellion against a particular authority or perhaps the very war itself? Have you taken into account the adrenaline or noradrenaline responses of your body or the distortions resulting from the "tunnel vision" inherent to the trauma?

8. If you killed for the exhilaration of killing or feeling powerful, and you now have questions about your behavior, have you taken into account the fact that war creates the conditions that can lead men to enjoy killing?

9. How are you punishing yourself today for any of the actions or inactions you listed? Are your self-punishments serving to remedy the original situation? For example, assume that during combat you had to kill children because they were armed with grenades and about to blow up your unit. Are you punishing yourself now by hating yourself or making yourself a distant ungiving father to your own children? Is your self-punishment in any way assisting the dead children or their families? What are the real effects of your self-punishment?

10. Can you think of any constructive ways to handle the guilt you feel regarding your wartime behavior?

11. Have you considered talking over your guilty feelings and the incidents that provoked these feelings with counselors trained in combat trauma, with other veterans, or with a minister or other spiritual advisor whom you trust?
- Matsakis PhD, Aphrodite; I Can’t Get Over It: A Handbook for Trauma Survivors; New Harbinger Publications, Inc: California; 1992

Personal Reflection Exercise #6
The preceding section contained information about survivor guilt and self-blame.  Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
The Burden of Survivorship: Survivor Guilt and Its Association
with Psychiatric Sequelae in COVID-19 Patients

- Palladini, M., Mazza, M. G., Scalabrini, A., Rovere Querini, P., Poletti, S., & Benedetti, F. (2023). The Burden of Survivorship: Survivor Guilt and Its Association with Psychiatric Sequelae in COVID-19 Patients. Journal of clinical medicine, 12(9), 3117. https://doi.org/10.3390/jcm12093117

Peer-Reviewed Journal Article References:
Assink, M., van der Put, C. E., Meeuwsen, M. W. C. M., de Jong, N. M., Oort, F. J., Stams, G. J. J. M., & Hoeve, M. (2019). Risk factors for child sexual abuse victimization: A meta-analytic review. Psychological Bulletin, 145(5), 459–489. 

Boysen, G. A., & Prieto, L. R. (2018). Trigger warnings in psychology: Psychology teachers’ perspectives and practices. Scholarship of Teaching and Learning in Psychology, 4(1), 16–26.

Callahan, J. L., Maxwell, K., & Janis, B. M. (2019). The role of overgeneral memories in PTSD and implications for treatment. Journal of Psychotherapy Integration, 29(1), 32–41.

QUESTION 20
According to the author, why is survivor guilt no longer one of the formal criteria for diagnosing PTSD? To select and enter your answer go to Test.