Commentary
Many shades of guilt
Guilt in patients with suicidal tendencies is a profoundly spiritual issue.
Suicidal behavior is a major cause of morbidity and mortality in the United States,1 and active-duty and reserve military personnel and veterans account for nearly 18% of suicide deaths.2 By one estimate, as many as 22 veterans die by suicide each day.3 These rates are thought to be due to a higher incidence of mental illness in certain veteran populations relative to the general population.4–8 Consequently, a number of mental health services are available to veterans in a variety of clinical and community settings.
Chaplains and clinicians bring complementary skills and services to the problem of suicide risk among veterans. In particular, helping at-risk veterans deal with experiences of guilt is an opportunity for interdisciplinary collaboration. Available literature supports the potential utility of chaplaincy services in supporting at-risk veteran populations.9–15
But while most healthcare facilities have chaplains on staff, there is little information to guide any such collaboration. Further, healthcare providers appear to have a limited understanding of chaplaincy services, the “language” within which chaplains operate, or the roles chaplains play in healthcare settings.16
In the following discussion, using the example of experiences of guilt, we offer our insights and suggestions on how chaplaincy services may prove useful in alleviating this complex emotion in veterans at risk of suicide.
BENEFITS OF TALKING TO A CHAPLAIN
Collaboration between healthcare providers and pastoral care professionals has been suggested as a means of enhancing the treatment of patients with mental illness.17,18 Chaplains draw from a variety of faith traditions and are usually trained to respond to the needs of people from a variety of religious and spiritual backgrounds. They provide some non-faithbased services (eg, crisis intervention, life review, bereavement counseling) resembling those also provided in formal mental healthcare settings.19 By facilitating religious and spiritual coping and religious practice and responding to religious and spiritual needs, chaplains also offer a level of support not typically offered by formal mental healthcare providers.20
Veterans at risk of suicide sometimes look to pastoral care providers, particularly chaplains, for mental health support.9,10 Research on the effects of chaplaincy services on suicidal behavior is just beginning to emerge.15 Still, the US Department of Health and Human Services has recognized pastoral care services as having a “beneficial and therapeutic effect on the medical condition of a patient.”11
For example, in one study, hospital inpatients reported higher satisfaction if they had been visited by a chaplain.12 Chaplains help align treatment plans with patient values and wishes.13 In another study,14 patients undergoing coronary artery bypass grafting who were randomized to receive five visits from a chaplain were found to have a higher rate of positive religious coping (eg, forgiveness, letting go of anger). Positive religious coping has been correlated with lower levels of psychological stress and better mental health outcomes.
EXPERIENCING GUILT IS LINKED TO RISK OF SUICIDE
Suicidal behavior is complex, multifaceted, and linked to genetic, neurologic, psychological, social, and cultural factors.21
Assessing for and addressing certain complex emotions, such as guilt and shame, is an important part of suicide prevention efforts. Guilt is defined as a “controllable psychological state that is typically linked to a specific action or behavior, and which entails regret or remorse.”22
Guilt has been linked to risk of suicide in veterans.23–25 In one study, close to 75% of veterans who had thought about suicide said they frequently experienced guilt about having violated the precepts of their faith group, family, God, life, or the military.26
Such findings suggest that the sense of guilt experienced by some at-risk veterans may be grounded in a variety of contexts. For example, faith communities that place a strong emphasis on obedience to moral, ethical, and religious precepts may contribute to the experience of guilt unless balanced by a message of grace or favor from a benevolent God or deity. Without this balance, engaging in activities that are not fully sanctioned by one’s faith community may lead to guilt.
Families might also contribute to veterans’ experiences of guilt by placing unrealistic expectations on them. And the family environment may not be conducive to resolving feelings of guilt in veterans, harboring resentment and antipathies and making it very difficult to alleviate any ensuing sense of distress.
CLINICIAN’S ROLE IN ASSESSING GUILT
In addressing and assessing guilt in veterans at risk of suicide, clinicians should try to recognize the source and clinical implications of this emotion.
Recognize the source of guilt
Guilt may indicate a clinical disorder such as a mood disorder (eg, major depression).27 Mood disorders significantly increase the risk of suicidal behavior.28,29
Beyond diagnosing a clinical disorder, prescribing pharmacotherapy, and referring for mental healthcare services, recognizing the source of this emotion remains an important part of addressing a patient’s experience of guilt. Especially when associated with a clinical disorder, guilt is often irrational and excessive and does not appropriately reflect the experience or situation in question.
Case conceptualization, defined as “synthesizing the patient’s experience with relevant clinical theory and research,”30 can be used to understand the context in which the guilt-inducing action or behavior occurred and the veteran’s own interpretation of his or her actions. Understanding the source of the patient’s guilt could be used to plan treatment and resolve any underlying sense of distress.
As with other negative emotions, the affective component of guilt is often the result of cognitive distortions made as the person tries to make sense of what has occurred or to reconcile beliefs of right and wrong with the guilt-inducing behavior.31 The common cognitive errors associated with guilt include:
- Hindsight bias (a belief that one should have known what was going to happen as a result of one’s actions)
- Responsibility distortion (a belief that one’s actions directly caused an adverse event)
- Justification distortion (a belief that one’s actions were not justified by the situation)
- Wrongdoing distortion (a belief that one violated one’s own standards of right and wrong).31
Cognitive therapy to counter cognitive distortions
A variety of clinical options exist to help veterans manage and resolve guilt.
Cognitive therapy can counter the cognitive distortions that drive feelings of guilt. The goal is to guide patients to examine the evidence, process the event, and realize that their behavior was appropriate for the given situation. Cognitive processing therapy and prolonged exposure therapy have both been shown to decrease trauma-related guilt, though cognitive processing therapy was found to be better at decreasing guilt that arose from cognitive distortions.32
Guilt and suicide ideation have also been associated with a belief that one’s actions constituted an unforgivable sin.33 Responding to these inherently religious-spiritual cognitive distortions may be beyond the scope of expertise for many healthcare professionals. In such cases, it may be prudent to consider complementing clinical services with pastoral care. It follows that pastoral care services should only be provided if the veteran voices a desire and readiness for them. The clinician and chaplain can then work together to provide coordinated care to best meet the patient’s needs, to address the experience of guilt, and to alleviate the sense of distress.