The Relationship Between Guilt, Changes in Psychological Distress, and Marital Satisfaction Among Couples Undergoing Cognitive Behavioral Conjoint Therapy (CBCT)

Post-Traumatic Stress Disorder (PTSD) may develop following exposure to a traumatic event perceived as posing a real threat to the physical safety of oneself or others. PTSD is characterized by clusters of symptoms including intrusion, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity, all of which may impair overall functioning (American Psychiatric Association, 2013). PTSD-related distress is associated with challenges in couple communication, emotional distancing, and strain on intimate relationships. Consequently, individuals coping with PTSD and their partners often report lower levels of intimacy and relationship satisfaction (ניסים ואחרים, 2019).

Post-traumatic guilt refers to feelings of guilt experienced after surviving or witnessing a traumatic event (Kubany & Watson, 2003). This type of guilt is common among trauma survivors and has been associated with more severe PTSD symptoms. Beyond its impact on individual psychological functioning, post-traumatic guilt has significant interpersonal implications, particularly within intimate relationships (Campbell & Renshaw, 2018; Norman et al., 2018). Feelings of guilt may contribute to emotional withdrawal, difficulty sharing traumatic experiences, avoidance of intimacy, and compensatory or appeasing relational patterns that undermine authenticity and mutuality within the relationship. Thus, post-traumatic guilt may function not only as a symptom accompanying PTSD distress, but also as a factor that exacerbates impairment in relational functioning and contributes to reduced relationship satisfaction. Previous findings suggest that post-traumatic guilt may serve as a mediating variable in the association between PTSD symptom severity and interpersonal impairment (Norman et al., 2018).

In line with the cognitive model of PTSD (Ehlers & Clark, 2000), guilt-related cognitive distortions—such as excessive self-blame, hindsight bias, and perceptions of unjustified responsibility—may emerge as part of the individual’s attempt to process the traumatic event. These distortions contribute to avoidance behaviors, emotional distancing, and impaired interpersonal communication, which represent central mechanisms through which PTSD distress affects couple dynamics (Dekel & Monson, 2010; Ehlers & Clark, 2000; Monson et al., 2010). Accordingly, post-traumatic guilt may be conceptualized as a potential mediating factor in the relationship between PTSD symptom severity and relationship satisfaction, making it a central mechanism for understanding change processes within the current study.

Despite growing recognition of the role of post-traumatic guilt in the interpersonal consequences of PTSD, empirical research remains limited regarding its role within intimate relationships, particularly as a mechanism of change in therapeutic interventions. In the Israeli context, although clinical reports indicate high prevalence and intensity of guilt among combat veterans exposed to traumatic events, this phenomenon has yet to be systematically examined empirically (מיץ, 2024). These gaps highlight the need for further examination of the role of post-traumatic guilt in dyadic change processes, as well as the way post-traumatic guilt changes throughout couple-based therapeutic interventions.

Cognitive Behavioral Conjoint Therapy (CBCT) for PTSD is a couple-based treatment protocol designed to reduce PTSD symptoms and improve relationship functioning and relationship satisfaction (Monson & Fredman, 2012). CBCT has been shown to be effective in reducing PTSD symptom severity and psychological distress, as well as improving relationship satisfaction (Monson et al., 2024). However, most studies examining the effectiveness of this intervention have been conducted in Western countries outside Israel, and empirical knowledge regarding its effectiveness among Israeli populations exposed to ongoing and unique traumatic experiences remains limited.

The present study aimed to examine the effectiveness of CBCT in reducing PTSD symptoms, post-traumatic guilt, and psychological distress, compared to a waitlist control group. In addition, the study examined the role of post-traumatic guilt as a mediating variable in the relationship between changes in PTSD-related distress and changes in relationship satisfaction (among both individuals coping with PTSD and their partners), while comparing differences between the treatment and waitlist groups.

Method: This study employed a randomized controlled quantitative experimental design and was conducted as part of a broader ongoing research project at the "Ripples for Recovery" clinic, within the School of Social Work at Bar-Ilan University. The sample included 46 heterosexual couples over the age of 18, in which one partner had been diagnosed with PTSD. Data were collected using self-report questionnaires and a semi-structured clinical interview for PTSD assessment at two time points: pre- and post-treatment/waitlist. Measures assessed PTSD symptoms, post-traumatic guilt, psychological distress, and relationship satisfaction. Data analysis included Repeated Measures MANOVA and moderated mediation analyses using the PROCESS procedure.

The findings indicated a significant reduction in PTSD distress and post-traumatic guilt among participants in the treatment group compared to the waitlist group. Regarding psychological distress, reductions were found in both groups; however, no significant between-group differences emerged. In addition, no significant increase in relationship satisfaction was found among either individuals coping with PTSD or their partners. Nevertheless, a positive trend in relationship satisfaction was observed among participants in the treatment group. Furthermore, within the treatment group, a significant positive correlation was found between changes in relationship satisfaction among individuals coping with PTSD and their partners, whereas this correlation was not significant in the waitlist group. However, the direct comparison between the correlation coefficients was not significant; therefore, this finding should be interpreted only as a descriptive indication of a possible coordinated dyadic process of change. These findings suggest that relational change may initially manifest through dyadic patterns, even when not reflected in significant mean-level changes before and after the intervention.

The moderated mediation analysis revealed that the association between reductions in post-traumatic guilt and improvements in relationship satisfaction was significant among participants in the treatment group. In addition, the indirect effect of changes in PTSD symptoms on changes in relationship satisfaction through changes in post-traumatic guilt was significant only in the treatment group.

Thus, the findings of this study point to the unique contribution of trauma-focused couple therapy, not only in reducing post-traumatic symptoms, but also in linking intrapersonal processes of change with changes in the couple’s relational dynamics. These findings highlight the importance of post-traumatic guilt as a central mechanism in this process and underscore the need to address it when planning couple-based interventions focused on post-traumatic stress disorder.