# Motivation and emotion/Book/2020/Survivor guilt

* Multimedia presentation (3 min)

## Overview

What makes trauma victims feel guilty for surviving an event where others did not? Evolutionary, behavioural, psychodynamic, philosophical and social learning theorists all discuss guilt as an emotion - why we need it, and why it helps us. However, only recently have psychologists explored the topic of survivor guilt and its relationship to trauma and Post-Traumatic Stress Disorder. Why it happens, what it feels like and how it can be overcome will be analysed to reveal the nature of survivor guilt and its impact on the individuals who struggle from it.
* Define guilt as an emotion
* Discuss psychological theories related to guilt
* Define survivor guilt and its relation to Post Traumatic Stress Disorder
* Identify symptoms and causation of survivor guilt
* Explore current research into survivor guilt
* Discuss treatment for survivor guilt

## Guilt as an emotion

Guilt has been discussed by a number of theorists as being a key stage of emotional and social development. From a social learning perspective, we can discuss Erikson's Stages of Psychosocial Development (a theoretical structure devised in the 1950's[grammar?]). The theory proposes that guilt and its associated emotions are developed in Stage 3 (3-5 years) where purpose, inhibition and maldevelopment become present. Bandura's Social Learning Theory and Social Cognitive Learning Theory discuss guilt in relation to observational learning and reference the importance of guilt as an emotion in regulating behaviours and self discipline.[factual?]
When looking at guilt from an evolutionary perspective we can discuss Charles Darwin's theories on natural selection and view guilt as a protective factor. Emotions of guilt are significant in maintaining effective relationships and moderating behaviours. Theories of emotional evolution emphasise the importance of cooperation and the role of emotional development and regulation in behavioural restraint. Recent medical hypotheses discuss the idea of negative legacy emotions in an evolutionary light and signify the imperative nature of the human ability to feel and understand guilt.[factual?]
From a behavioural perspective, guilt plays a role in promoting successful behavioural change by introducing the averse emotions associated with undesired action and becomes key in motivating improved behaviours through negative reinforcement during behaviour modelling. Guilt discourages behaviours that could become threatening and unhelpful in any given social situation and promotes positive behavioural associations between individuals and their environment. Bandura emphasises the importance of guilt in creating internalised standards for 'proper' social behaviours which promote healthy, non-destructive relationships. Behavioural theories of guilt emphasise the emotion as being imperative for cooperation and acceptance.[factual?]
Psychodynamic theories reinforce the role of guilt in regulating the ego and super-ego. Psychoanalytic reflections on guilt and conscience discuss how guilt is a product of the tension between the ego and super ego and is present the expression of unconscious thought. Emotions of guilt regulate points of human morality and conscience. Furthermore, psychoanalytic theorists also discuss the absence of guilt evasion in narcissistic behaviours. Guilt and associated emotions are paramount in moral regulation and conscious thought and are important in the conceptualising of human thought. Freudian ideas reflect on the importance of guilt regulation in the expression of true self and the repression of false self and reflect on individual expression guilt as being closely tied with self reflections on identity.[factual?]
Philosophical journals enlighten ideas of virtue and the role of guilt in a social context. Guilt promotes intention or duty within individuals psyche and creates internal ethical measures. Notions of guilt and virtue are commonly mentioned by philosopher Aristotle where modern theorists have developed similar ideas. Self conscious emotions are imperative in the social functioning of individuals. Hegel discusses the Philosophy of Right and interprets guilt as a socially constructed emotion that drives moral obligation. Wundt's theories of introspective thought display guilt as a basic emotional concept important in developing and maintaining helpful associations in social settings.[factual?]
Theories of psychological resilience discuss how the notion of guilt comes with psychological risk and protective factors. This emotion is paramount for social learning, societal functioning and self-discipline as well as playing important roles the psychodynamic reflections on ego and super-ego. Guilt remains an important aspect of human emotion and allows us to experience empathy and connection with others. Along with the protective factors of guilt that allow us to inform ourselves of the moral obligations that distinguish our identities, guilt in excess can contribute to a number of risk factors that jeopardise mental health. Guilt is a focal point for a number of therapies and recovering from the phenomenon is crucial in the recovery process as it underlies the intrusive thoughts at the root of depression and anxiety. Guilt is heavily associated with shame which may have a negative effect on an individuals self-esteem.[factual?]

### The biological psychology of emotion

The limbic system is responsible for the recognition and regulation of emotion.
Brain structures involved in the recognition and regulation of emotion :
| | Location | Function |
| Amygdala | Temporal Lobe | Regulates emotion by processing sensory information and communicating signals to hypothalamus |
| Hypothalamus | Forebrain | Receives sensory information and releases hormones that activate the Autonomic Nervous System |
| Hippocampus | Medial Temporal Lobe | Encodes emotional context and processes emotional thought |
Biological structures play a role in the release of hormones as a response to emotional recognition in an attempt to regulate emotional stimuli. The adrenal gland, pituitary gland and hypothalamus are involved in hormonal responses.
Hormones and emotion :
| | Associated emotion | Biological response |
| Endorphins | Stress | Inhibits communication of pain signals |
| Oxytocin | Love, bonding, well-being | Promotes bodily relaxation |
| Serotonin | Regulated mood and happiness | Regulates overall body function |
| Dopamine | Happiness, good mood. | Increases heart rate and heightens body function |
| Cortisol | Stress | Increases heart rate and triggers 'fight or flight' responses |

#### The neurobiological response to guilt

The temporal lobe, frontal lobe and limbic structures of the brain are biological components associated with feelings of guilt and shame as they play a vital role in the generation of moral interpretation. The neural stimuli involved in regulating and processing guilt are aroused when behaviour contradicts conscientious thought which leads to increased activity in the amygdala and frontal lobe and decreased activity in the left and right hemispheres of the brain. The neurological arousal of guilty emotional responses is linked with disparities between action and the brains learned social standards. Cortisol is released by the adrenal gland as a biological response to guilt.

#### Key questions

* What are the key psychological theories surrounding guilt?
* Which key brain structures play a role in emotional recognition and regulation?

## Survivor Guilt

"Most recent theorists have held the classical view that survivor guilt is a form of pathological mourning in which the individual felt guilty for aggressive feelings towards the lost object, these feelings being suppressed." (British Journal of Psychotherapy, 1996.)

### What is Survivor Guilt?

The DSM-5 specifies survivor guilt as a symptom of Post-Traumatic Stress Disorder (PTSD)[factual?]. Post-Traumatic Stress Disorder 309.81 (F43.10) classifies associated feelings of shame and guilt as a components of a persistent negative emotional state. The presence of guilt and shame are factors that lead towards the diagnosis of PTSD however not all individuals with survivor guilt are diagnosed with PTSD. Survivor guilt is also known as survivor syndrome and survivor disorder and it's[grammar?] symptoms can be in co-occurrence with those of stress and trauma related disorders and mood disorders and anxiety disorders such as Major Depressive Disorder and Generalised Anxiety Disorder 300.02 (F41.1).[factual?]
Survivor guilt is mainly characterised by the negative emotional experience of guilt in excess and occurs when an individual who has lived through a traumatic event experiences feels that they are to blame for the death, injury or misfortune of others after recovering from a traumatic event where others did not. Guilt is often seen as a form of grieving for the loss of others however must be distinguished as a separate phenomenon. This psychological occurrence is common for war veterans, cancer survivors, and survivors of major accidents as well as individuals who receive transplants from deceased persons. Survivors guilt is often associated with Post Traumatic Stress Disorder (PTSD) and is currently noted as a key symptom for the diagnosis of PTSD.[factual?]
Though a recently new field of study, theories suggest that survivor guilt is a humans empathetic response to witnessing loss where they remain fortunate whilst others may not have. Witnessing trauma not only creates psychological discomfort but also influences how individuals see themselves and leaves survivors questioning their actions in response to events that lead to loss. Survivor guilt brings intense regret, shame and destructive self-reflection, occurring as a result of social conditioning through environmental learning mechanisms which begins early in the life span. From a young age individuals develop aversive emotions to negative experiences and empathise with those surrounding them. Survivors guilt is also experienced as the traumatic events that cause the condition are generally events where victims have witnessed and experienced situations that are in conflict with their personal moral standards thus leading to self-blame and an overwhelming responsibility for actions taken/not taken. Social learning, evolutionary and behavioural perspectives explain much of the phenomenon of survivor guilt.[factual?]
Psychologists highlight self-esteem as being imperative to mental well-being as it shapes our identities and influences how we view ourselves and the world around us. Self-esteem allows individuals to deal with daily stressors and maintain self-regulation which promotes healthy behaviours that are beneficial to their physical and mental well-being. Self-esteem is built from how we view ourselves in relation to our environment and our responses to the situations around us; guilt introduces doubt which reflects negatively on self-esteem thus leading to poor relationships, depression and anxiety. Individuals who suffer from survivor guilt regret their responses during a traumatic event and view their actions as being insufficient or wrong [grammar?] therefore the intrusive thought patterns that occur as a result may chip away at the self-esteem needed to recover from and overcome trauma as those with low self-esteem feel the need to self-sabotage and doubt their ability to recover.[factual?]
Attributional styles play a key role in the occurrence of survivor guilt. Individuals with negative attributional styles tend to blame themselves and their personal actions for the situations that surround them and believe that they are at fault in any outcome. Guilt and shame also have the ability to shape an individuals[grammar?] attributional style and studies have found that individuals who experience survivor guilt are more likely to show an attitude that says "this is all my fault, I am to blame" than individuals who are not experiencing excessive guilt or shame as a result of trauma. A review on shame and guilt discusses the link between attributional style and survivor guilt; "the shame-prone and the depressed share a tendency to make "internal, stable, and global attributions" for negative events (117)--both groups seeing themselves as always to blame for everything." (Tangney, Dearing. 2002.) This source discusses the adaptive, other-oriented and empathetic nature of guilt thus explaining how individuals experiencing survivor guilt after witnessing the misfortune of others have been conditioned to feel guilty as a result of our adapted, human responses to situational ques that trigger feelings of empathy. The moral emotional styles of guilt that individuals learn at the beginning of their lifespan are responsible for the occurrence of survivor guilt as humans feel a sense of obligation to feel a certain way in response to any given situation.[factual?]
Individuals diagnosed with survivor guilt may experience the following symptoms:
* Anxiety
* Dissociation
* Flashbacks
* Depression
* Sleep disturbances
* Intrusive thoughts (which can often stem from a level of overwhelming responsibility and regret)
Survivor guilt is a psychological disorder[Earlier it was stated that it is not a stand-alone disorder; clarify] that often occurs when an individual feels that they are in the wrong for surviving a traumatic event. Individuals who live through events that caused death or physical and emotional harm to others involved feel overwhelming responsibility for the outcome that may have negatively impacted others involved. The psychological phenomenon is described by Nancy Sherman as “counterfactual thoughts that you could have or should have done otherwise, though in fact you did nothing wrong.” There are a number of situations that can provoke symptoms of survivor guilt and the following are examples of common occurrences;[factual?]
* Car crash events
* Natural disasters
* Holocaust survivors
* War veterans
* Transplant receivers
* Sexual assault
Individuals who experience survivor guilt present a number of symptoms that can be disruptive to their everyday life whilst causing a high degree of psychological stress when not addressed;[factual?]
* Feelings of guilt for what they did/didn't do during the traumatic event
* Irritability
* Obsessive thoughts
* Helplessness
* Fear
* Lack of motivation
* Dissociation
* Confusion
* Suicidal thoughts
* Depression
* Anxiety
* Sleep disturbances
* Avoidance
* Isolation

### Survivor guilt and PTSD

Survivor guilt is often a common occurrence for sufferers of PTSD and both conditions present similar symptoms. Trauma-related guilt following an event can become a debilitating condition which affects intrusive thought patterns and provokes suicide ideation. Survivor guilt is a focal treatment point for sufferers of PTSD and inattention to trauma related guilt may decrease treatment progression. War veterans have expressed feeling guilt in correlation with PTSD flashbacks that may occur when experiencing regret for not helping another soldier on the battle field or witnessing the death of another soldier.[factual?]
Case Study: Trauma Informed Guilt Reduction Therapy With Combat Veterans
Victims of sexual assault also experience survivor guilt as a symptom of PTSD. Individuals present symptoms of guilt where they express an overwhelming responsibility for their reactions to the situation that lead to their trauma. Sufferers of assault may experience intrusive thoughts that are self-blaming and may continuously assess the situation and its outcomes had they responded differently. This unhelpful behaviour does not promote emotional healing and may prolong treatment. Depressive, regretful and shameful thoughts that stem from underlying guilt are closely linked with PTSD symptoms.[factual?]
Case Study: Guilt, Isolation and Hopelessness Among Female Survivors of Sexual Abuse: Effectiveness of Group Work Intervention.
Holocaust survivors are a key focal point in the discovery and awareness of survivor guilt as a psychological condition separate to other PTSD and guilt-related experiences. Psychologists researching the PTSD symptoms of holocaust survivors found an identical presence of guilt in sufferers and reflected on the similarities between experience and impact. A case study that focuses on the survivor guilt experienced by Holocaust survivors discusses themes of powerlessness, anxiety, loss and torture and maintains that the guilt felt by sufferers of trauma is separate to ordinary emotions of guilt. Survivor guilt as a symptom of PTSD involves the re-experiencing of trauma and the overwhelming responsibility of intense regret.[factual?]
Case Study: The Holocaust and the Power of Powerlessness: Survivor Guilt an Unhealed Wound
Individuals who have witnessed the death of a loved one or been involved in events that have resulted in serious injury are common sufferers of PTSD and present symptoms of survivor guilt. Regret for how they responded to the event or for the fact that they survived when others didn't are frequent thoughts for individuals who are diagnosed with the psychological condition. Similar to this, individuals who are recipients for organ transplants from donors who have passed experience survivor guilt as they gained health and fortune from the misfortune of others and their families. A case study from a clinical sample analysed and measured the presence of symptoms of guilt in individuals who are diagnosed with PTSD after having witnessed death or were involved in life threatening events and found an overwhelming result that showed 90% of survivors felt a degree of guilt for their ability to overcome and live through events that others may have not.[factual?]
Survivor Guilt in a Post traumatic Stress Disorder Clinic Sample

### Survivor guilt and current research

Research into the nature of survivor guilt was sparked during studies on victims of the Holocaust. In the 1960's multiple psychological analysis were being carried out on Holocaust survivors to gain insight into how the traumatic events effected[grammar?] their mental state. Researchers found that a large number of survivors suffered from guilt, shame and intrusive thought as a result of their trauma and many survivors would state that they wish they acted and responded differently in a number of situations that cost the lives and wellbeing of other individuals. Although, researchers could not identify all of the diagnostic criteria for Post Traumatic Stress Disorder in many survivors, the similarities in thought and emotion for most of the individuals rose curiosity which inspired an entire field of research into the notion of survivor guilt as a differentiated psychological condition which can be distinguished from other cases of guilt, shame and stress. Authors of Trauma Informed Guilt Reduction Therapy With Combat Veterans reiterate the contribution of this awakening to modern psychological theories and therapies and state that "posttraumatic guilt has been identified as having a role in the development and maintenance of several forms of posttraumatic psychopathology". (Norman, Wilkins, Myers, Allard. 2014.)
Case study The holocaust and the power of powerlessness: survivor guilt an unhealed wound, dives into the previously insufficient psychological theories for guilt and shame in relation to trauma in which there is a lack of focus on how certain emotions plague survivors who live through life-changing events. The self-blaming behaviours of holocaust survivors raised questions about current psychodynamic theories and intrigued new modern ideas that would link trauma to guilt and attempt to lighten this weight of self-blame which is described as a psychic defence for inhumane treatment and powerlessness amid psychological torment. A medical journal titled Survivor Guilt in a Posttraumatic Stress Disorder Clinic Sample discusses how research into survivor guilt as a psychological contruct was first driven; "Survivor guilt was first documented and described in psychoanalytic writings about the Holocaust (Neiderland, 1968) and Hiroshima survivors (Lifton, 1967)."(Murray, 2017). As a new psychological concept, research into the autonomy of survivor guilt as an emotional experience separate to other concepts of guilt, shame and stress has sparked debate as well as an influx of theoretical contributions that attempt to understand the phenomenon.
Key questions
* What are the symptoms of survivors guilt?
* What can the case studies tell us about the relation between PTSD and survivor guilt?
* Why do individuals experience survivors guilt?

## Overcoming Survivor Guilt

[Provide more detail]

### Treatment

There are several current treatment options that work towards symptom management and psychological healing for trauma victims who suffer with survivor guilt. Therapy options are considered the most effective in maintaining effective treatment for survivor guilt however there are a number of medications that help to mediate the disruptive symptoms that are co-morbid with survivor guilt sufferers.[factual?]
Psychologists working with individuals suffering survivor guilt may ask individuals the following questions;
* Who is truly responsible?
* How do people who love you feel about your survival?
* Could you have done anything to prevent the incident form happening in the first place?
Victims of survivor guilt need their thoughts to be rationalised in a safe environment as the majority of their concern is self-induced, imaginary and irrational.[factual?]

#### Steps towards treatment for survivor guilt

The first key step in working towards overcoming any mental health condition is to seek help. For many individuals this may be the most difficult step in their journey to recovery as it involves vulnerability, transparency and strength. There are factors that may prevent individuals from seeking help; they may feel that their work/personal life could be jeopardised or they may fear that they have to re-live traumatic events throughout their treatment.[factual?]
The next step in overcoming survivor guilt is psychological evaluation which will identify the nature of the individuals condition and act as a basis to enhance effective long-term treatment. Psychological evaluation will also bring to the surface any other underlying psychological conditions that may be responsible for the presence of embodied symptoms as well as identifying the event that is responsible for the individuals negative emotional state.[factual?]
The third step in the treatment process for survivor guilt is to receive therapy that employs specific, helpful coping strategies. There are a number of therapies that are effective in the treatment for survivor guilt; group intervention therapy, cognitive behavioural therapy, psychodynamic therapy and interpersonal therapy. Eye movement desensitisation therapy is also commonly used for the treatment of survivor guilt when it is suffered as a result of Post-Traumatic Stress Disorder. Therapeutic methods are intended to identify and confront the issue, work through associated feelings and introduce strategies for coping with and overcoming trauma.[factual?]
The use of pharmaceuticals is often common in combination with therapy when individuals suffer low mood and anxiety as a result of their trauma. Mood regulating medications can help the effectiveness of therapeutic treatment however the use of pharmaceuticals alone will have an ineffective treatment response. Anti-depressants help with decreasing depressive symptoms during the treatment of survivor guilt.[factual?]

#### Key Questions

* What are the current treatment options for survivor guilt?
* How effective are the current treatment options for survivor guilt?

## Conclusion

Guilt is an adverse emotion that derives from undesired action or a breach in interpersonal moral expectations which we develop from our selves and our environments. This self conscious emotion is important in social interaction and allows us to form meaningful relationships and control destructive behaviour. Despite the protective factors it embodies, guilt in excess holds many risk factors and is destructive to an individuals[grammar?] wellbeing. Survivor guilt is an example of how destructive the nature of this emotion can become when paired with trauma and psychological distress. Theorists discuss the evolutionary need for guilt and its importance for learning and development however little is discussed about how it can negatively effect[grammar?] the mental health of those who fall victim to survivor guilt. As a symptom associated with Post-traumatic Stress Disorder, survivor guilt follows trauma and sufferers often embody excessive intrusive thoughts, symptoms of depression, disruptions to sleep and anxiety and these symptoms often affect the daily functioning and recovery for trauma victims.[factual?]
Being a newly discovered psychological phenomenon the question often stands; why do victims of trauma experience survivor guilt? The numerous psychological perspectives try to explain the occurrence and a number of theories are discussed and explored however all share a common theme; survivor guilt is an emotion experienced as a result of psychological trauma and is present for those who relive their trauma regularly. Survivor guilt forces victims to feel as if they are to blame for their trauma. The phenomenon occurs as a result of shame felt when victims feel that they could have avoided their trauma or that of others by acting differently at the time it occurred and in some cases is felt as part of the grieving process for those who did not survive. The intrusive thoughts occur when individuals are not in acceptance of what they experienced and have not yet come to terms with how their trauma has effected[grammar?] them therefore they develop regret, shame, anxiety and dissociation. Survivor guilt is a common occurrence of PTSD and the self-blaming nature of the condition is detrimental to the health and well-being of victims.
Case studies show the effect that survivor guilt has on individuals who experience it and express how the aftermath of trauma in some cases is lifelong. The nature of humans to experience empathy may be involved in how and why we experience guilt for not being more helpful or reacting in a certain way however this irrational thought pattern that leads victims to self-blaming behaviours is possibly a built in mechanism that we have learnt and developed through out[grammar?] our lifespan. The embodiment of such a profound level of guilt and shame inhibits the healing process for victims and leads them to psychological distress however therapeutic and pharmaceutical treatments can work towards overcoming the effects of survivor guilt.[factual?]