# Non-Inferiority Trial of Trauma Informed Guilt Reduction Therapy (TrIGR) for PTSD

> **NIH VA I01** · VA SAN DIEGO HEALTHCARE SYSTEM · 2023 · —

## Abstract

Trauma-related guilt is common and impairing among trauma survivors, particularly among treatment seeking
Veterans with posttraumatic stress disorder (PTSD). Guilt is a distressing emotion that arises when trauma
survivors blame themselves for the outcome of a traumatic event and guilt turns to shame when people judge
not just their actions but themselves negatively because of what happened. Guilt is positively associated with
severity of PTSD and depression symptoms, suicidal ideation, poorer psychosocial functioning, and shame.
Among those with PTSD, guilt is one of the symptoms likely to persist after PTSD treatment, suggesting further
intervention targeting guilt is needed.
Although evidence-based trauma-focused PTSD treatments such as Cognitive Processing Therapy (CPT) are
effective to treat PTSD and trauma-related guilt, many still experience symptoms or maintain their diagnosis
after treatment, and dropout from these generally 12+ session protocols is high. Veterans show lower
response and higher dropout than others with PTSD. Delivering protocols that are generally 12 or more
sessions challenges the Veterans Affairs (VA) healthcare system given high demand for mental health care.
For these reasons, additional and less burdensome approaches are needed. Brief treatment that targets
mechanisms that are distressing and associated with multiple problems and disorders may be an understudied
but promising way to treat PTSD and other posttraumatic psychopathology. Our work shows that a brief
treatment targeting trauma-related guilt and shame, Trauma Informed Guilt Reduction Therapy (TrIGR), can
reduce guilt, PTSD, depression, and distress among Veterans and help them reengage with activities they find
meaningful. In a preliminary efficacy study with 144 OEF/OIF/OND Veterans with guilt from a deployment
trauma, we found large effects in PTSD symptom reduction and moderate effects in depression symptom
reduction in TrIGR compared to supportive therapy. More than 50% lost their PTSD diagnosis and two thirds
showed clinically meaningful change. Dropout was low and attendance was high - Veterans attended more
than five of six sessions on average. Whether TrIGR is no less effective than longer, more resource heavy
evidence-based PTSD treatments disseminated across by VA, like CPT, is the next critical question.
The proposed randomized clinical trial (RCT) will be the first non-inferiority trial of TrIGR and the first to
compare TrIGR to a first tier PTSD treatment, specifically CPT. It will also be the first to evaluate TrIGR with
Veterans from all eras with guilt from any type of traumas, as our previous work was exclusively with Veterans
of the conflicts in Iraq and Afghanistan with deployment-related traumas. 158 Veterans across two VA sites will
be randomized to TrIGR or CPT. Exclusion criteria will be minimal so that generalizability will be high.
Treatment will be delivered in VA mental health clinics. The primary aim is to evaluate if TrIGR is n...

## Key facts

- **NIH application ID:** 10584430
- **Project number:** 1I01CX002584-01
- **Recipient organization:** VA SAN DIEGO HEALTHCARE SYSTEM
- **Principal Investigator:** SONYA NORMAN
- **Activity code:** I01 (R01, R21, SBIR, etc.)
- **Funding institute:** VA
- **Fiscal year:** 2023
- **Award amount:** —
- **Award type:** 1
- **Project period:** 2023-04-01 → 2028-03-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10584430

## Citation

> US National Institutes of Health, RePORTER application 10584430, Non-Inferiority Trial of Trauma Informed Guilt Reduction Therapy (TrIGR) for PTSD (1I01CX002584-01). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/10584430. Licensed CC0.

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