Journal of Traumatic Stress

xxxx 2018, 00, 1–8

Impact of Self-Blame on Cognitive Processing Therapy:

A Comparison of Treatment Outcomes
Laura E. Stayton,1 Benjamin D. Dickstein,1 and Kathleen M. Chard1,2
1
Cincinnati VA Medical Center, Trauma Recovery Center, Cincinnati, Ohio, USA
2
University of Cincinnati College of Medicine, Department of Psychiatry and Behavioral Neuroscience, Cincinnati, Ohio, USA

Research suggests that cognitive processing therapy (CPT) may be a particularly well-suited intervention for trauma survivors who endorse
self-blame; however, no study has examined the impact of self-blame on response to CPT. Accordingly, the current study compared
response to CPT between two groups of veterans seeking residential treatment for posttraumatic stress disorder (PTSD). In one group,
participants endorsed low self-blame at pretreatment (n = 133) and in the other group, participants endorsed high self-blame (n = 133).
Results from multilevel modeling analysis suggest that both groups experienced significant reductions in PTSD symptoms as measured
by the PTSD Checklist, B = −1.58, SE = 0.11; 95% CI [−1.78, −1.37]; t(1654) = −14.97, p < .001. After controlling for pretreatment
symptom severity and additional covariates, there was no difference in treatment response between the low- and high-self-blame groups,
Time × Self-blame interaction: B = 0.18, SE = 0.12; 95% CI = [−0.06, 0.42]; t(1646) = 1.49, p = .138. This suggests that CPT is an
effective treatment for individuals exposed to trauma, regardless of level of self-blame.

With the release of the Diagnostic and Statistical Manual
of Mental Disorders (5th ed.; DSM-5; American Psychiatric
Association [APA], 2013), the diagnostic criteria for posttrau-
matic stress disorder (PTSD) were revised to fit with the results
of factor analytic studies that suggested PTSD comprises a
four-factor structure (Friedman, Resick, Bryant, & Brewin,
2011). This revision included adding a new symptom cluster
(“negative alterations in cognition and mood”) and, within this
cluster, the symptom of “distorted blame of self or other” (APA,
2013). Self-blame involves distressing cognitions concerning
one’s role in causing a trauma (APA, 2013), and some consider
self-blame to be a component of moral injury (i.e., distress
resulting from morally incongruent behavior; Gray, Nash, &
Litz, 2017). A national survey conducted by Cox, Resnick, and
Kilpatrick (2014) found that self-blame was significantly higher
among individuals who developed PTSD following trauma
exposure, suggesting that this added symptom is warranted.
Previous research has investigated changes in self-blame
across treatment with cognitive processing therapy (CPT).
Results suggest that self-blame decreases over the course
The authors would like to sincerely thank all of the staff at the Trauma Recovery
Center. The content of this manuscript does not reflect the views of the United
States Government or Department of Veterans Affairs.
Correspondence concerning this article should be addressed to Laura Stayton,
PhD, Cincinnati VA Medical Center, Ft. Thomas Division, 1000 S. Ft. Thomas
Ave., Fort Thomas, KY 41075. E-mail: Laura.Stayton2@va.gov
Copyright  C 2018 International Society for Traumatic Stress Studies. View
of CPT (Owens, Chard, & Cox, 2008) and that changes in
self-blame temporally precede changes in PTSD symptoms
among CPT recipients (Schumm, Dickstein, Walter, Owens,
& Chard, 2015). Interestingly, Rizvi, Vogt, and Resick (2009)
found that a higher level of guilt (an emotion that is thought
to result from self-blame cognitions) at pretreatment was
associated with an increased response to CPT, suggesting
that CPT works particularly well when guilt (or, by proxy,
self-blame) is a prominent feature of affective distress.
These findings fit with the theoretical underpinnings of CPT,
which targets problematic beliefs resulting from trauma in
an effort to resolve distressing emotions (Resick, Monson, &
Chard, 2017). Alleviation of self- or other-blame cognitions,
or what CPT terms “assimilated beliefs,” is prioritized early in
treatment, with the focus subsequently shifting to other prob-
lematic cognitions, including those related to issues of safety,
trust, power/control, esteem, and intimacy, or what are referred
to as “over-accommodated beliefs” (Resick et al., 2017).
Preliminary evidence suggests that CPT may hold some ad-
vantage over other trauma-focused therapies for reducing guilt
and associated self-blame. In a study of female sexual assault
survivors, Resick, Nishith, Weaver, Astin, and Feuer (2002)
found that participants who received CPT reported larger re-
ductions in certain aspects of guilt compared with those who re-
ceived prolonged exposure (PE) therapy. This was an important
finding, given the limited research findings to date that inform
treatment selection. Considering the early emphasis CPT places
on challenging self-blame and its effectiveness in reducing

this article online at wileyonlinelibrary.com guilt, the treatment may be particularly helpful for patients who
DOI: 10.1002/jts.22289 endorse high levels of self-blame. No study to date appears to

1
 Stayton, Dickstein, & Chard

have directly examined this, however, leaving it unclear whether Procedure

level of self-blame should influence treatment selection.
Accordingly, in the current study, we aimed to determine
whether baseline levels of self-blame would impact treatment
effectiveness among a sample of military veterans receiving
CPT. Given that previous findings have shown that higher lev-
els of guilt at pretreatment predict increased response to CPT
(Rizvi et al., 2009) and the heavy emphasis that the CPT proto-
col places on targeting self-blame cognitions, we hypothesized
that individuals who endorsed higher levels of self-blame at
pretreatment would benefit more from CPT than those with
lower levels of self-blame, as evidenced by a greater reduction
in PTSD symptoms.
Method
Participants
Participants were selected from a larger sample of veter-
ans who had been admitted to a residential PTSD treatment
program. The primary study sample was derived by including
only those veterans who scored in the highest and lowest quar-
tiles on a measure of self-blame. We excluded individuals who
endorsed moderate self-blame (middle two quartiles; n = 202)
from primary analyses. This process resulted in a sample of 266
veterans who had been admitted to a residential PTSD men’s
(n = 177) or women’s (n = 89) treatment program at a Veterans
Affairs (VA) Medical Center in the Midwestern United States
between November 2008 and October 2013. Veterans who are
admitted to the treatment program are referred from a VA or
community provider, or may be self-referred. The majority of
veterans in our sample met full diagnostic criteria for PTSD
(n = 258) or subthreshold PTSD (n = 8) at admission as as-
sessed using the Clinician Administered PTSD Scale (CAPS;
Blake et al., 1995). Exclusionary criteria for admission to the
program included current untreated psychosis, substance de-
pendence, a medical condition that may interfere with full
participation in the program, or current suicidal or homici-
dal ideation with intent or plan. For a summary of pretreat-
ment demographic information, please see Table 1. To de-
termine whether results were affected by dichotomizing the
self-blame variable, we conducted additional analyses with the
entire sample of veterans, including those who reported low,
moderate, or high self-blame based on a continuous variable.
These analyses included a total sample of 468 veterans. Among
the 202 individuals who endorsed moderate self-blame, mean
age and education were 47.8 (SD = 10.82) and 13.5 years
(SD = 3.01), respectively. Most of these veterans were Cau-
casian (56.9%), reported sexual assault as their index trauma
(43.1%), and served in the post-Vietnam or Persian Gulf eras
(51.5%). In addition, the mean pretreatment scores for the Beck
Depression Inventory (BDI-II; Beck, Steer, & Brown, 1996),
PTSD Checklist–Specific Stressor Version (PCL-S; Weathers,
Litz, Herman, Huska, & Keane, 1993), and CAPS were 33.91
(SD = 10.24), 64.72 (SD = 10.33), and 74.41 (SD = 16.55),
respectively.
Data utilized in this study were collected as part of routine
clinical care within a specialty PTSD clinic at a VA medical
center in the Midwestern United States. The analysis of archival
data was approved by the institutional review board and the VA
Office of Research and Development.
Assessments were administered as part of the admission to
the residential treatment program to determine fit. Veterans also
completed PCL-S assessments at weekly therapy sessions to
determine progress toward treatment goals. Finally, clinician-
administered and self-report measures were conducted prior
to discharge from the treatment program to determine current
symptom severity upon completion of programming. The pro-
gram (as outlined in the Procedure section) consisted of two
individual and group CPT sessions per week; however, assess-
ments only took place at one of the weekly individual appoint-
ments. This resulted in available PCL-S data for all patients at
pre- and posttreatment, as well as data assessed at six of the
12 CPT sessions. Of note, given variability in scheduling, ad-
ministration of the PCL at individual sessions was not always
uniform across all veterans; accordingly, the available data at
each time point are somewhat variable.
Participants in our study were enrolled in a PTSD residential
treatment program that consisted of a 7-week delivery of CPT
in a combined individual and group format (Chard, Resick,
Monson, & Kattar, 2009). The combined format included two
75-min group sessions per week to allow veterans to practice
skills and learn from other group members. Each veteran also
attended two individual sessions per week to focus on process-
ing trauma-related thoughts and emotions. In addition to CPT,
veterans participated in a variety of psychoeducational group
programming. For more information about the residential treat-
ment program, please see Walter, Varkovitzky, Owens, Lewis,
and Chard (2014).
Measures
PTSD symptoms. The PCL-S (Weathers et al., 1993)
is a 17-item self-report measure of PTSD symptoms. Each
symptom is rated on a scale of 1 (not at all) to 5 (extremely),
with total scores ranging from 17 to 85. The PCL-S has
been found to have sound psychometric properties, including
excellent internal consistency (Cronbach’s α = .97; Weathers
et al., 1993), and may also be utilized as a repeated measure to
determine symptom change across treatment (Monson et al.,
2008). A 10- to 20-point change is considered clinically mean-
ingful (Monson et al., 2008). Participants were administered
the PCL-S at admission, discharge, and once per week during
treatment. The data for the current study were collected as part
of routine clinical care, and item-level data were not available
in archival chart review; therefore, internal consistency values
of the current sample are unavailable.
Depression. The BDI-II (Beck et al., 1996) is a 21-item
self-report measure of depression symptoms. Each symptom is

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
 Self-Blame in Cognitive Processing Therapy

Table 1
Comparison of Pretreatment Characteristics in Veterans With High Self-Blame and Low Self-Blame
Low Self-Blame High Self-Blame
Characteristic M SD n % M SD n % Statistical Test p
PTCI-SB 1.61 0.46 5.82 0.60 t(247.27) = −64.32 < .001
Age (years) 48.54 12.88 47.53 9.99 t(248.54) = 0.71 .477
Sex χ²(1, N = 266) = 3.80 .051
Men 96 72.2 81 60.9
Women 37 27.8 52 39.1
Education (years) 13.31 1.82 13.42 1.84 t(264) = −0.50 .616
Race/Ethnicitya t(2) = 2.01 .366
Asian American 0 0.0 1 0.8
African American 52 39.1 41 30.8
Hispanic/Latino 2 1.5 3 2.3
Native American 0 0.0 1 0.8
White 76 57.1 86 64.7
Race/Ethnicity
Other 2 1.5 0 0.0
Multiracial 1 0.8 1 0.8
Service Erab χ²(2, N = 265) = 15.99 < .001
Vietnam 45 34.1 26 19.5
Post-Vietnam 34 25.8 57 42.9
Persian Gulf 20 15.2 30 22.6
Iraq/Afghanistan 33 25.0 20 15.0
Employment Statusc χ²(1, N = 266) = 0.118 .732
Full-time 16 12.0 13 9.8
Part-time 3 2.3 8 6.0
Student 5 3.8 1 0.8
Unemployed 38 28.6 53 39.8
Disabled 49 36.8 51 38.3
Employment Status
Retired 22 16.5 5 3.8
Other 0 0.0 2 1.5
Marital Statusd χ²(2, N = 266) = 2.58 .276
Married 39 29.3 17 12.8
Never married 24 18.0 27 20.3
Remarried 5 3.8 9 6.8
Divorced 55 41.4 61 45.9
Separated 8 6.0 11 8.3
Widowed 2 1.5 8 6.0
Index trauma typee χ²(2, N = 266) = 32.24 < .001
Combat 55 41.4 22 16.5
Physical assault 8 6.0 5 3.8
Sexual assault 35 26.3 78 58.6
Childhood sexual abuse 7 5.3 9 6.8
Other 28 21.1 19 14.3
PCL-S total score 61.50 11.99 66.62 9.90 t(254.84) = −3.80 < .001
CAPS total score 71.18 17.86 77.14 15.25 t(264) = −2.93 .004
BDI-II total score 29.14 12.15 40.23 10.17 t(256.02) = −8.07 < .001
Depressive disorder 92 69.2 99 74.4 χ²(1, N = 266) = 0.91 .340
Substance use disorder 8 6.0 7 5.3 χ²(1, N = 266) = 0.07 .790
(Continued)

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
 Stayton, Dickstein, & Chard

Table 1
Continued
Low Self-Blame High Self-Blame
Characteristic M SD n % M SD n % Statistical Test p
Bipolar disorder 13 9.8 18 13.5 χ²(1, N = 266) = 0.91 .339
Panic disorder 7 5.3 20 15.0 χ²(1, N = 266) = 6.97 .008
Psychotic disorder 5 3.8 7 5.3 χ²(1, N = 266) = 0.35 .555
Anxiety/OCD dis. 12 9.0 22 16.5 χ²(1, N = 266) = 3.37 .066
Note. N = 133 for the low-self-blame group; N = 133 for the high-self-blame group. Valid percentages reported. PTCI-SB = Posttraumatic Cognitions Inventory–Self-
Blame subscale; PCL-S = PTSD Checklist–Specific Stressor Version; CAPS = Clinician Administered PTSD Scale; BDI-II = Beck Depression Inventory – II; OCD
= obsessive compulsive disorder.
a To ensure appropriate cell counts in chi-square analysis, variables were collapsed as follows: White, African American, and other race/ethnicity. b To ensure appropriate

cell counts in chi-square analysis, variables were collapsed as follows: Vietnam, Iraq/Afghanistan, and other. c To ensure appropriate cell counts in chi-square analysis,
variables were collapsed as follows: working and not working. d To ensure appropriate cell counts in chi-square analysis, variables were collapsed as follows:
married/remarried/widowed, separated/divorced, and never married. e To ensure appropriate cell counts in chi-square analysis, variables were collapsed as follows:
combat; sexual trauma; and other.

rated on a scale of 0 to 3 based on the degree to which the par-
ticipant has experienced that symptom within the past 2 weeks,
with higher numbers indicating a greater severity of symptoms.
Scores on the measure range from 0 to 63. The measure has
demonstrated good internal consistency with Cronbach’s alpha
values ranging from .86 to .88 (Beck & Steer, 1984).
unavailable, precluding calculation of internal consistency.
For the purpose of this study, self-blame was captured as one
categorical variable with participants categorized as having
either high (n = 133) or low (n = 133) self-blame by examining
quartiles according to PTCI Self-Blame subscale scores, as
previously described.

PTSD. The CAPS (Blake et al., 1995) is the gold-standard

Trauma-related thoughts and beliefs. The Posttraumatic
Cognitions Inventory (PTCI; Foa, Ehlers, Clark, Tolin, &
Orsillo, 1999) consists of 36 items that measure negative cogni-
tions related to a specific trauma on a scale of 1 (totally disagree)
to 7 (totally agree). Items are summed to generate a total score
and averaged to generate three subscales: Negative Beliefs
About the Self (21 items), Negative Beliefs About the World
(seven items), and Self-Blame (five items). Previous research
has found that the Self-Blame subscale of this measure demon-
strates good internal consistency, with a Cronbach’s alpha value
of .86, as well as moderate convergent and discriminant validity
(Foa et al., 1999). Some researchers have argued that the Self-
Blame subscale demonstrates poorer psychometric properties
relative to the other PTCI scales (Beck et al., 2004); however,
internal consistency values for the Self-Blame subscale have
consistently been acceptable, with reported Cronbach’s alpha
values of .73 in a sample of Turkish college students (Gulec,
Kalafat, Boysan, & Barut, 2013), .75 in a culturally diverse
sample of female Spanish sexual assault survivors (Andreu,
Pena, & Angeles de La Cruz, 2017), .81 in a sample of motor
vehicle accident survivors (Beck et al., 2004), and .83 in a
sample of Chinese college students (Su & Chen, 2008). Most
relevant to the current sample, a recent study of veterans with
a history of military-related trauma found that the Self-Blame
subscale demonstrated good internal consistency (Cronbach’s
α = .84; Sexton, Davis, Bennett, Morris, & Rauch, 2018).
Unfortunately, given that the current dataset was derived from
clinical chart reviews of archival data, item-level data were
assessment for diagnosis of PTSD. The structured clinical in-
terview provides information on whether an individual meets
DSM-IV-TR-based diagnostic criteria for PTSD and provides
a severity rating of symptoms (APA, 2000). Given that the di-
agnostic criteria in DSM-5 includes self-blame as a symptom
(APA, 2013), we utilized assessment data collected under the
previous diagnostic system to minimize overlap between our
independent variable and study outcome. The CAPS has been
shown to have excellent psychometric properties, including a
Cronbach’s alpha value of .94 for the total score (Blake et al.,
1995).
Axis I disorders. The SCID-I (First et al., 1995) is a
semistructured interview used to assess a wide variety of di-
agnostic conditions including mood, substance use, psychotic,
and anxiety disorders. In the current study, we used the SCID-I
to assess for comorbid psychiatric conditions. The instrument
has demonstrated moderate to excellent interrater reliability
with kappa values ranging from 0.61 to 0.83 (Lobbestael,
Leurgans, & Arntz, 2011).
Data Analysis
We checked data for univariate and multivariate outliers using
boxplots and the Mahalanobis distance test. Two multivariate
outliers were removed prior to further analyses. Preliminary
independent samples t tests and chi-square analyses were
conducted to determine any baseline differences between the

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
 Self-Blame in Cognitive Processing Therapy
high- and low-self-blame groups. Several categorical variables
(i.e., race/ethnicity, service era, employment status, marital
status, and index trauma) were collapsed for the purpose of
ensuring adequate cell counts for chi-square analyses (see
Table 1 footnotes). We employed the Benjamini and Hochberg
procedure for false discovery rate to control for conducting
multiple independent tests (Benjamini & Hochberg, 1995).
We performed multilevel modeling (MLM) using IBM SPSS
Statistics (Version 22; IBM SPSS, 2013) to compare self-blame
groups on treatment outcome. There are a number of advantages
to using MLM over typical repeated-measures approaches (i.e.,
repeated measures analysis of variance [ANOVAs]), namely
its ability to use maximum likelihood estimation for handling
missing data, its increased statistical power, and its lack of as-
sumption regarding sphericity (Gueorguieva & Krystal, 2004).
To determine whether the current sample size would afford
adequate statistical power, a power analysis was conducted us-
ing the G*Power software package (Faul, Erdfelder, Lang, &
Buchner, 2007). We examined potential power of a repeated
measures, within-between group interaction. Assumptions of
this analysis included a small effect size (f = 0.05), an alpha
value of .05, two groups, 13 measurements, a correlation among
repeated measures of .70, and a nonsphericity correction of 1.
This analysis indicated that 81 participants per group (N = 162)
would be associated with a power of .80 to detect the small ef-
fect size. This analysis suggests that the current sample was
sufficient to detect even a very small effect. As noted above,
MLM provides better power than ANOVA; therefore, results
from this analysis can be viewed as conservative.
In each model, the PCL-S was entered as the dependent
variable. The PCL-S was administered at pretreatment, post-
treatment, and at weekly CPT sessions (with a maximum of 13
CPT sessions). Time was centered at Session 1 and coded from
0 to 14. Prior to testing the study hypotheses, a series of mod-
els were conducted to determine which covariates were most
important to include. If a covariate was significantly associated
with treatment response, as determined by the p value associ-
ated with fixed-effects parameters in the preliminary model, it
was included as a covariate in the model. Preliminary models
were also conducted to test the quadratic effect of time on PTSD
symptoms.
Results
We compared pretreatment characteristics of the low- and
high-self-blame groups using a series of mean comparisons
and chi-square tests. Results suggested that at baseline, groups
significantly differed in terms of service era, index trauma, pre-
treatment PCL-S score, pretreatment CAPS score, pretreatment
BDI-II score, and panic disorder diagnostic status (see Table 1
for a full report of pretreatment differences). There was no sig-
nificant difference in the average number of PCL-S data points
available between participants in the low-self-blame group
(M = 6.11, SD = 2.24) and those in the high-self-blame group
(M = 6.33, SD = 1.99), t(259.67) = −0.87, p = .383.
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
We conducted a preliminary model to assess the impact of
treatment alone on PCL-S score, without accounting for co-
variates. We entered PCL-S as the dependent variable and time
as a covariate. The results of this model suggested a main ef-
fect of time on self-reported PTSD symptoms, measured by
the PCL-S, B = −1.47, SE = 0.08, 95% CI [−1.63, −1.33],
t(1,654) = −19.31, p < .001. A baseline model was run to test
the effect of a Time × Self-Blame interaction prior to adding
covariates, as suggested by Kraemer (2015). We entered PCL-
S as the outcome variable, and added time, self-blame, and
the interaction as predictors. Results indicated that the effect
of time remained significant, B = −1.58, SE = 0.11, 95% CI
[−1.78, −1.37], t(1,654) = −14.97, p < .001. There was also
a significant main effect of self-blame B = −6.62, SE = 1.20,
95% CI [−8.97, −4.27], t(1,654) = −5.53, p < .001. How-
ever, the Self-Blame × Time interaction was nonsignificant,
B = 0.19, SE = 0.15; 95% CI [−0.10, 0.49], t(1,654) = 1.29,
p = .197.
We ran a final preliminary model to determine whether base-
line characteristics predicted response to CPT over the course of
treatment and test the quadratic effect of time on PTSD symp-
tom severity. We used the PCL-S as the outcome variable and
included time, the quadratic effect of time, and the identified
baseline variables (i.e., service era, index trauma, panic dis-
order diagnosis, pretreatment BDI-II score, and pretreatment
CAPS score) as predictors. Results indicated a main effect of
linear time, B = −0.96, SE = 0.22, 95% CI = [−1.39, −0.53],
t(1,646) = −4.41, p < .001; and quadratic time, B = −0.04,
SE = 0.02, 95% CI [−0.07, −0.01], t(1,646) = −2.44, p = .015.
Other variables found to significantly predict PCL-S across time
included trauma type (note that combat was used as the refer-
ence group for each individual comparison); sexual trauma,
B = −3.95, SE = 0.75, 95% CI [−5.41, −2.48], t(1,646) =
−5.26, p < .001; other trauma, B = −2.74, SE = 0.84, 95% CI
[−4.40, −1.10], t(1,646) = −3.27, p = .001; Vietnam-era ser-
vice (note that Iraq/Afghanistan was used as the reference group
for each analysis), B = 3.45, SE = 0.90, 95% CI [1.69, 5.22],
t(1,646) = 3.84, p < .001; other service era, B = 1.89, SE =
0.84, 95% CI [0.24, 3.53], t(1,646) = 2.25, p = .025; CAPS total
score at pretreatment, B = 0.33, SE = 0.02, 95% CI [0.28, 0.37],
t(1,646) = 15.15, p < .001; and BDI-II score at pretreatment,
B = 0.36, SE = 0.03, 95% CI [0.30, 0.42], t(1,646) = 11.98, p <
.001. Panic disorder diagnosis, B = −0.45, SE = 0.96, 95% CI
[−2.34, 1.43], t(1,646) = −0.47, p = .636, was nonsignificant
in predicting treatment outcome and was therefore not included
in the final model.
In the final model, PCL-S was entered as the dependent
variable; self-blame status, index trauma, and service era were
entered as factors; and time, quadratic time, pretreatment CAPS
score, and pretreatment BDI-II score were entered as covari-
ates. The model estimated fixed effects of the noted variables
as well as the Time × Self-Blame interaction. Full results of
the final model are also shown in Table 2. The main effects
of time and self-blame remained significant after controlling
for covariates. In contrast, the Time × Self-Blame interaction
 Stayton, Dickstein, & Chard

Table 2 estimated marginal means at each time point are reported in

Results of Multilevel Modeling Analysis Testing Effect of Time Table 3 and depicted graphically in Figure 1.
and Self-Blame on Self-Reported Posttraumatic Stress Disorder In order to determine whether the final model evidenced bet-
(PTSD) Symptom Severitya ter fit than our baseline model described above, we conducted
a nested, chi-square difference test using the -2 log likelihood
Parameter B SE tb p
(-2LL) values obtained from our baseline model (i.e., that which
Intercept 30.64 1.89 16.18 .000*** included only time, self-blame, and their product term as pre-
Time −1.05 0.23 −4.67 .000*** dictors) and our final model (i.e., that which also contained
Quadratic time −0.04 0.02 −2.42 .016* covariates). The -2LL values for these models were 13533.22
Service erac (df = 4) and 12790.70 (df = 11), respectively. This difference of
Vietnam 3.45 0.89 3.85 .000*** 742.51 (df = 7) is significantly greater than the critical value for
Other era 1.85 0.84 2.21 .027* chi-square at p value of .05 of 14.07, suggesting that our final
Index Traumad model evidenced better model fit. We also ran a final model that
Sexual trauma −4.31 0.79 −5.46 .000*** included random effects and compared it to the model described
Other trauma −2.86 0.84 −3.39 .001* here. As expected, model fit improved with the inclusion of ran-
Pretreatment CAPS 0.33 0.02 15.29 .000*** dom effects, -2LL = 11850.80, df = 14; however, there were no
Pretreatment BDI-II 0.34 0.03 10.27 .000*** substantive differences in the primary results, and the Time ×
Self-Blamee −2.20 1.05 −2.09 .037* Self-Blame interaction remained nonsignificant, B = 0.11,
Time × Self-Blame 0.18 0.12 1.49 .138 SE = 0.14, 95% CI [−0.17, 0.40], t(284.9) = 0.78, p = .437.
Given that there have been documented problems with
Note. N = 266. CAPS = Clinician Administered PTSD Scale. BDI-II = Beck dichotomizing a continuous variable (MacCallum, Zhang,
Depression Inventory.
a The checklist was used to measure self-reported PTSD symptom severity. Preacher, & Rucker, 2002), we ran an additional model us-
b df = 1,646. c The comparison group for service era was veterans who served in ing self-blame as a continuous predictor to determine whether
Iraq/Afghanistan. d The comparison group for index trauma was combat. e Self- results were compromised due to our method of dichotomizing
blame status was calculated using the Posttraumatic Cognitions Inventory Self- self-blame. This analysis included all individuals regardless of
Blame subscale, with those in the top quartile rated as high and those in the reported level of self-blame and resulted in a sample of 468
bottom quartile rated as low.
*p < .05. ***p < .001.
veterans (n = 133 low self-blame, n = 202 moderate self-
blame, and n = 133 high self-blame). In this model, we entered
PCL-S as the dependent variable, and continuous pretreatment
was nonsignificant, suggesting that the impact of treatment did self-blame, time, quadratic time, and a Time × Self-Blame in-
not differ between participants with low- and high self-blame teraction were entered as predictors. There were main effects
at pretreatment. Time was centered at pretreatment, and the of time, quadratic time, and self-blame; however, the Time ×

Table 3
Estimated Marginal Means at Each Time Point, Using a Multilevel Modeling Approach with Maximum Likelihood Estimation
Low Self-Blame (n = 133) High Self-Blame (n = 133)
Time point M SE Available n M SE Available n
0 63.61 0.81 133 65.81 0.83 133
1 62.70 0.68 13 64.72 0.71 22
2 61.72 0.60 100 63.56 0.63 92
3 60.66 0.56 25 62.32 0.59 20
4 59.53 0.55 81 61.01 0.58 93
5 58.33 0.56 18 59.62 0.59 15
6 57.06 0.57 65 58.17 0.60 71
7 55.71 0.58 25 56.64 0.61 24
8 54.29 0.58 73 55.03 0.61 83
9 52.79 0.59 30 53.35 0.61 20
10 51.22 0.59 72 51.60 0.62 82
11 49.58 0.62 23 49.78 0.64 23
12 47.87 0.68 38 47.88 0.69 39
13 46.08 0.78 5 45.91 0.79 11
14 44.21 0.92 111 43.86 0.93 114

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
 Self-Blame in Cognitive Processing Therapy

Figure 1. Response to residential posttraumatic stress disorder (PTSD) treatment with cognitive processing therapy (CPT) in military veterans with high and low
self-blame. PCL-S = PTSD Checklist–Specific Stressor Version; Session 0 = pretreatment; Session 14 = posttreatment. For both low- and high-blame groups,
n = 133.

Self-Blame interaction was nonsignificant. Full results of this equally from CPT. These findings are inconsistent with those
model are shown in Table 4. These results are consistent with reported by Rizvi et al. (2009), who found that increased lev-
our primary analysis in suggesting that participants benefited els of guilt and symptom severity at pretreatment resulted in
from CPT regardless of the level of self-blame they reported at greater treatment gains with CPT. Given our current findings,
pretreatment. clinicians may feel more comfortable utilizing CPT, even when
individuals do not report high levels of guilt or self-blame at
treatment onset.
Discussion Although this study provided novel findings with direct clin-
The current study examined the effectiveness of residential ical application, there were also notable limitations. First, given
CPT treatment for reducing PTSD symptoms in veterans who that data were obtained from participants in a residential treat-
reported low and high levels of self-blame at pretreatment. Al- ment program with multiple components, it cannot be deter-
though previous research has examined changes in guilt across mined what proportion of improvement is related to CPT. Sec-
CPT treatment, no study, to our knowledge, has assessed the ond, given that the data were collected as part of routine clinical
impact of self-blame on treatment outcome. Results of MLM care, the frequency of PCL-S administration varied across par-
analysis demonstrated a significant effect across time, suggest- ticipants, leading to larger amounts of missing data. Third, only
ing that veterans’ self-reported PTSD symptoms improved at self-report data were used to determine treatment outcome.
each CPT session. After controlling for pretreatment differ- Future research should consider using clinician-administered
ences in demographic characteristics and PTSD and depres- outcome data. Fourth, in order to examine differences between
sive symptoms, there was no Time × Self-Blame interaction, groups, we created a categorical self-blame variable, which
suggesting that individuals in both groups benefited relatively may have resulted in loss of information; however, our results,
including a continuous measure of self-blame, also resulted in a
nonsignificant interaction. Lastly, given the nature of data col-
Table 4 lection, we were unable to calculate the internal consistency of
Results of Multilevel Modeling Analysis Testing Effect of Time the Self-Blame subscale of the PTCI, which has demonstrated
and Self-Blame as a Continuous Variable on Self-Reported Post- variable, albeit consistently acceptable, Cronbach’s alpha val-
traumatic Stress Disorder (PTSD) Symptom Severity ues in previous research.
Parameter B SE t df p Despite these limitations, this study had a number of
strengths, including our use of a “real world” clinical sam-
Intercept 59.44 1.07 55.41 2,782 < .000 ple, well-validated measures, longitudinal design, and MLM.
Time −0.68 0.23 −2.98 2,782 .003 Lastly, the results are clinically relevant, as providers may
Time × Time −0.04 0.14 −3.15 2,782 .002 now feel confident recommending CPT for veterans regard-
Self-Blamea 1.49 0.25 5.91 2,782 < .000 less of where they fall on the self-blame continuum, possibly
Time × Self-Blame −0.50 0.03 −1.42 2,782 .155 including moral injury, an area for future research. In addi-
Note. N = 468.
tion, future studies might consider whether the current find-
a Self-blame was entered as a continuous predictor including those who reported ings generalize to outpatient samples and whether results hold
low, moderate, and high levels of self-blame. over time.

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
 Stayton, Dickstein, & Chard
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