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CBT for people who believe they've done something unforgivable
Jim Pretzer · 06/04/03 at 9:11 ET
A good assessment and an individualized understanding of the client's problems is the foundation of effective CBT. Your query does not give enough information to allow me to propose a treatment approach but I'll comment on several possibilities: 1. Depressed individuals sometimes dwell on past transgressions and exaggerate their significance while ignoring factors which might make their actions more understandable and acceptable. Often it is guite helpful to assist the client in identifying their negative thoughts and looking critically at them. It can also be helpful to have the client explaing how they would react to someone else who committed the same acts which the client did. Often, depressed individuals are much harsher in responding to their own transgressions than they are in responding to the transgressions of others. When this is the case, it can be useful to examine the pros and cons of responding harshly to one's own transgressions. 2. If the individual experiences unwanted, intrusive thoughts that they may have done something terrible, the problem may be Obsessive-Compulsive Disorder rather than depression. It is not unusual for individuals to be obsessed with the thought that they may have inadvertantly harmed someone, may have molested a child, may have committed blasphemy, etc. When this is the case, attempts to reassure the individual or to convince the individual that he or she didn't do anything terrible usually are ineffective and may actually make the problem worse. Instead, prolonged imaginal exposure to the thoughts, fears, and imagined consequences is needed. 3. If the individual hears voices hears voices accusing him or her of having committed terrible acts, then antipsychotic medication is likely to be necessary. This could be followed by the interventions described in paragraph 1. 4. If the individual actually has committed an act which he or she believes is unforgiveable, it can be important to understand the individual's beliefs and the beliefs held by their family and culture. It is also important to understand the individual's, family's, and culture's beliefs about how one should respond to an individual who has committed their transgression. If there is a culturally sanctioned method for gaining absolution (such as making confession to a priest, submitting to the judgement of elders, making restitution to the victim's family, etc.) it can be useful to take advantage of this option. If the cultural/family/religious sanctions are unacceptably harsh, it may be necessary to help the individual to look critically at the cultural/family/religious beliefs and to consider whether they do, indeed, accept those beliefs. If there are any indications of PTSD, the individual may need treatment for PTSD as well. 5. In any of the scenarios discussed above, it can also be useful to explore the individual's beliefs about forgiveness and about the consequences of forgiveness. It is not unusual to encounter individuals who believe that forgiveness means that what the person did is OK. It is also common to encounter individuals who fear that, if they forgive themselves, this means that they will commit the act again in the future. When this is the case, it can be useful to address these misconceptions.
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