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, authors of a recent commentary say.

In the article, published in the Cleveland Clinic Journal of Medicine, two Cleveland Clinic spiritual care staff members argue that chaplains have a unique and valuable role to play in counseling military veterans.

The authors are Amy Elise Greene, Dmin, ACPE Supervisor, Director of Spiritual Care, Cleveland Clinic and Robert J. McGeeney, Dmin, ACPE Supervisor, Director of Clinical Pastoral Education, Cleveland Clinic and Chaplin (Major), US Army Reserve (ret.).

Rather than using logic to try to counteract a patient’s stated feelings, a religious authority can help ease guilt feelings by listening carefully and offering words that may include the hope of  forgiveness, but also do not minimize the realities being expressed, Drs. Greene and McGeeney write.

“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,” the authors write.

In their article, Drs.Greene and McGeeney propose four categories of guilt that can be effectively addressed by chaplains in concert with other members of the healthcare team: real guilt, survivor guilt, mistaken guilt, and complex-compound guilt.

1. Real Guilt — People who have hurt or killed people in warfare have often done so against their own moral codes. Even if their deeds were committed under orders, they may need to unburden their hearts and spirits. These feelings need to be aired and released in a safe and confidential environment. They can be helped by someone who is trained in nonjudgmental and nondirective listening. This can be done effectively by a religious authority who can assure the patient of his or her innate worthiness and ability to be forgiven.

2. Survivor Guilt — Those who suffer from survival guilt judge themselves unworthy of survival and believe the deceased to have been more courageous, virtuous, or a better person than they are. Some think, “It should have been me who was killed.” The burden of this feeling can be overwhelming if those who can’t be helped to see their own worth. Chaplains can help them to make meaning out of a life-changing event, rather than find meaning inherently in that event. Conversations about meaning and purpose can provide a compass for the disoriented survivor.

3. Mistaken Guilt — Someone who has been involved in the death of another but who is blameless and could not have prevented it sometimes takes the guilt on him or herself – in spite of the facts. The feelings of helplessness that result can be particularly hard to treat. Assurances may not help. Long-term intervention such as cognitive therapy can turn their minds away from destructive thoughts. They may unburden themselves by telling of past infractions to a chaplain.

4. Compound-Complex Guilt
   This combination of other types of guilt may leave those who have it feeling guilty for feeling guilty. They feel culpable for not being able to move on or forgive themselves. To this may be added the feeling of weakness for needing help or not asking for help. In a military culture where there is still some fear of stigma in asking for help — especially with mental health — chaplains can be an entry point for the veteran needing multiple professionals involved in his or her care.

Deep work

Many veterans suffering from guilt may need intensive pharmacologic or cognitive therapies, Dr. Greene says. A chaplain is not a substitute for psychological evaluation or treatment, especially if there is a risk for suicide.

“But we can help with the deep work of spiritual healing that is part of veteran’s overall recovery,” she says. “We are not only trained to do this, but we have a unique spiritual language that speaks to the condition.”

Dr. Greene believes that chaplains may sometimes be a less-threatening entry point for professional team care.

They are a less formal alternative, unconcerned about billable hours and skilled at building trust, she says.

“Many chaplains are quite gifted at creating an atmosphere of reverence and safety in the most unlikely situations,” Dr. Greene says. “Chaplains should be considered as part of any multidisciplinary team addressing the problem of veteran guilt in the healthcare setting.”