The Role of Posttraumatic Guilt and Anger in Integrated Treatment for PTSD and Co-Occurring Substance Use Disorders Among Primarily Male Veterans

Tanya C. Saraiya, Christal L. Badour, Alyssa C. Jones, Amber M. Jarnecke, Delisa G. Brown, Julianne C. Flanagan, Therese K. Killeen, Sudie E. Back

Research output: Contribution to journalArticlepeer-review


Objective: PTSD and substance use disorders (SUD) frequently co-occur among veterans. Integrated exposure- based treatments, such as Concurrent Treatment of PTSD and SUD Using Prolonged Exposure (COPE), are efficacious in reducing PTSD and SUD symptoms and posttraumatic emotions. This study examines whether guilt and anger (a) decreased in a randomized clinical trial comparing COPE with Relapse Prevention (RP) therapy for SUD and (b) mediated PTSD and SUD symptom reductions or vice versa. Method: Veterans (90.1% men) diagnosed with PTSD and SUD were randomized to 12 sessions of COPE (n = 54) or RP (n = 27). Guilt and anger were assessed at 10 time points during treatment. Multilevel linear models assessed changes in guilt and anger across treatments and lagged multilevel mediation analyses assessed within-subject change in guilt and anger predicting PTSD and percent days of substance use, and vice versa. Results: Guilt (B = -.12, SE =.02, p <.001) and anger (B = –.13, SE =.02, p <.001) improved in both treatments, however guilt was significantly lower in Sessions 7 through 11 among veterans receiving COPE. Improvement in guilt mediated PTSD symptom improvement in both treatment groups (B = –.08, SE =.04, 95% CI [–.16, –.01]), and PTSD symptom improvement mediated anger reduction in COPE (B = –.03, SE =.01, 95% CI [–.06, –.01]). The substance use models were insignificant. Conclusions: Among veterans, integrated, trauma-focused treatments may be associated with greater guilt (directly) and anger (indirectly) reductions due to processing trauma.

Original languageEnglish
JournalPsychological Trauma: Theory, Research, Practice, and Policy
StateAccepted/In press - 2022

Bibliographical note

Funding Information:
This work was supported in part by National Institute on Drug Abuse Grants R01 DA030143 (Principal Investigator [PI]: Sudie E. Back) and T32 DA007288 (PI: Jacqueline McGinty), National Institute on Alcohol Abuse and Alcoholism Grant K23 AA027307 (PI: Amber M. Jarnecke), and in partnership with the Office of Research on Women’s Health and theMedical University of South Carolina Grant U54 DA016511 (PI:McRae-Clark).

Publisher Copyright:
© 2022 American Psychological Association


  • Anger
  • Guilt
  • Ptsd
  • Substance use disorders

ASJC Scopus subject areas

  • Social Psychology
  • Clinical Psychology


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