Commentary

Many shades of guilt

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In their commentary, Kopacz et al1 propose that collaboration with professionally trained and certified clinical chaplains provides an opportunity for interdisciplinary care with increased benefit to veterans at risk of suicide. They rightly identify the pivotal issue of guilt as one that falls squarely in the domain of spiritual (or pastoral) care.

See related commentary

As professionals involved in the training of board-certifiable chaplains (and one of us is a veteran), we find that guilt in patients with suicidal tendencies is a profoundly spiritual issue that can be addressed effectively through collaboration among chaplains, physicians, and mental health providers.

Guilt is a serious spiritual condition that can easily be undertreated, or treated under the rubric of depression, which is related but not identical. Undertreatment occurs when caregivers, eager to see the guilt-sufferer experience relief, inadvertently short-circuit the necessary process of working through, rather than around, the guilt. Allowing patients to talk about their feelings of guilt without minimizing those feelings can be helpful even if, as Kopacz et al point out, the feelings are often irrational. We believe that people have an innate need to be truly heard and understood before they can become open to a reinterpretation of their feelings. Only then can the seeds of self-forgiveness begin to take root.

Hearing the words “There is hope for you to feel forgiven” can be more helpful than hearing “You didn’t really do anything bad,” particularly if the patient is religious. Hearing these words from a chaplain is often more effective than hearing them from a lay person, just as many of us take basic health information more seriously when we hear it from a physician. Even if the veteran is not overtly religious, there may be a unique exchange between that person and a religious authority when it concerns the violation of a millennia­old, widely known teaching from the Bible, such as “Thou shalt not kill.”

Guilt in patients with suicidal tendencies is a profoundly spiritual issue

Kopacz et al also rightly suggest that unless religious prohibitions have been balanced with teachings on forgiveness and grace, the teachings can actually exacerbate feelings of guilt and elevate them to harmful proportions, especially in the potentially vulnerable psyche of a veteran who may have been traumatized. If there is no religious or spiritual guidance for balancing prohibitions with graces, the patient may be left to spiral in an unending loop of guilt with no way out.

We therefore propose the following categories for different types (or “shades”) of guilt that can be effectively addressed by chaplains in concert with other members of the healthcare team. For simplicity, we call these types real guilt, survivor guilt, mistaken guilt, and complex-compound guilt.

REAL GUILT

An important role professional chaplains can play is to allow patients (in this case, veterans) to express their remorse and regret for violations of their own moral codes. In many cases, they have in fact hurt or killed another person, and they need the chance to unburden their hearts and spirits, especially if they were taught that killing people is a sin. Veterans who have harmed or killed others, even if under orders, are often left with bona fide feelings of guilt that need to be aired and released in a safe and confidential environment. This is often most effective when done by someone who not only is trained in nonjudgmental and nondirective listening, but also is a religious authority who can assure the patient of his or her innate worthiness and of the ability to be forgiven.

As Kopacz et al note, guilt is linked to a specific action or behavior and usually entails regret or remorse. Many veterans belong to or have had exposure to faith groups with strong moral codes and prohibitions, and so may see the chaplain as having authority to act as confessor and granter of absolution.

SURVIVOR GUILT

Survivor guilt is commonly understood as the feeling of surviving a terrible event or situation while someone else did not. Those who suffer from survivor guilt judge themselves unworthy of survival and believe the deceased to have been more courageous, virtuous, or somehow a better person than they. They torture themselves with ideas of the deceased person’s virtues—imagined or real—and sometimes go on to believe that “It should have been me who was killed.”

The burden of feeling that the wrong person died can be overwhelming. If these people are not helped to see their own worth and helped to find outlets for their sense of having been spared (by God, by their own wits, or by sheer luck), they are likely to struggle more. This is related but not identical to what we call mistaken guilt. The two types are similar because they share a sense of randomness and helplessness, but they are different for reasons we will explain below.

Chaplains can be particularly effective partners in the care of veterans with survivor guilt, helping them to make meaning out of a life-changing event, rather than find meaning inherently in that event. Meaning, purpose, and “God’s plan for my life” are common themes in the pastoral conversation that can provide a compass for the disoriented survivor.

MISTAKEN GUILT

Mistaken guilt describes when a person who is involved in the death of another but is absolutely blameless—and could not possibly have prevented that death—literally “mis-takes” the guilt upon himself or herself in spite of the facts. Because of the helplessness induced by this feeling, mistaken guilt can be more difficult to treat than other forms. These patients continue to suffer despite assurances that the death occurred through absolutely no fault of their own.2

‘There is hope to feel forgiven’ can be more helpful than ‘You didn’t do anything bad’

Hickling3 has written extensively about this phenomenon in innocent motor vehicle drivers who cause pedestrian deaths, and he considers this type of guilt one of the most difficult to recover from precisely because of the helplessness factor. He has explained that if patients can find a real reason by which they were culpable for what happened, they can change their ways. But if they were absolutely innocent (as in many incidents in training or combat), they often cannot make sense of what happened in a way that allows them to move on because there is nothing they could have done differently and therefore nothing they can change.4

These patients almost certainly need long-term intervention such as cognitive behavioral therapy in order to train their mind away from such destructive thoughts. However, they are also very likely to be helped by a chaplain if they find that the event triggers memories of other past infractions of which they may need to unburden themselves (ie, confess).

COMPOUND-COMPLEX GUILT

As the name implies, compound-complex guilt is a combination of the other types and may have additional layers.

Compound-complex guilt leaves sufferers literally feeling guilty for feeling guilty. Though this may border on a genuine clinical disorder, it is also to some degree normal (eg, due to cultural taboos and norms) for people to feel culpable for not being able to “move on” or “forgive themselves” as quickly as others may want them to. Buddhists call this tendency the “second arrow effect.” The first arrow is the feeling of guilt (or other painful feeling) that strikes the individual, but the second arrow is the one he or she drives in afterward by thinking it is wrong or weak to even have the feeling.

Patients who suffer from this type of guilt blame themselves for the conundrum they are in and feel even worse. This is not unlike the vortex of unresolved and complicated grief.

Those who suffer from compound-complex guilt may layer the primary guilt with additional guilt for feeling weak, for needing help, or for asking for help. Especially in the culture of the military, the fear of stigma when asking for help (especially with mental health) is still quite strong. Therefore, chaplains can serve as a less threatening entry point for the veteran needing multiple professionals involved in his or her care.

NONJUDGMENTAL LISTENING

Nonjudgmental listening is essential to get at the source or sources of guilt, regardless of the type, in order to allow the wounds to air out and begin healing. Many veterans suffering from guilt may need intensive pharmacologic and cognitive therapy to fully recover, and care from a chaplain is not a substitute for psychiatric evaluation and treatment, especially if there is a risk of suicide.

However, chaplains may be able to help with the “deep work” of spiritual healing that is part of veterans’ overall recovery. This is true not only because chaplains are especially trained to do this, but also because they are the team members most likely to have uniquely spiritual language to speak to the condition. The language of confession, absolution, repentance, redemption, atonement, and forgiveness is language of the spiritual realm.

In addition, chaplains’ freedom from hourly billing concerns and their often less formalized interactions with patients may help to build trust. Well-trained chaplains, who are often quite gifted at creating an atmosphere of reverence and safety (sanctuary) in the most unlikely situations, are well suited to help the interdisciplinary team treat this vulnerable patient population.

SUGGESTED READING

For more insights into the role of chaplains on the interdisciplinary healthcare team, we recommend the following book: Cadge W. Paging God: Religion in the Halls of Medicine. Chicago, IL: University of Chicago Press; 2012.

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