Veterans, guilt, and suicide risk: An opportunity to collaborate with chaplains?
================================================================================

* Marek S. Kopacz
* Kathy A. Rasmussen
* Robert F. Searle
* Barbara M. Wozniak
* Caitlin E. Titus

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.

*See related commentary, page [106](http://www.ccjm.org/lookup/doi/10.3949/ccjm.83a.15136)*

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, health-care providers appear to have a limited under-standing of chaplaincy services, the “language” within which chaplains operate, or the roles chaplains play in healthcare settings.16

In the following discussion, using the ex-ample 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-faith-based services (eg, crisis intervention, life review, bereavement counseling) resembling those also provided in formal mental health-care 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, pre-scribing 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.

## A CHAPLAIN’S PERSPECTIVE ON GUILT

A prominent feature of pastoral practice is helping people, including at-risk veterans, resolve feelings of guilt regardless of the context on which the emotion is founded (eg, religion, shame).10 For many people, guilt is an impenetrable barrier, preventing resolution of what-ever experience led to a sense of inner turmoil.

### Forgiveness

In the context of pastoral care, resolution of guilt is ordinarily tied to a need for forgiveness. There are multiple ways in which forgiveness can be grounded in religious and spiritual contexts.34 Examples include forgiving others (ie, forswearing resentment, anger, or hatred directed toward another person), being forgiven by God or another benevolent deity, and for-giving oneself for violating perceived personal transgressions.35 In some cases, divine forgiveness may be conditional on interpersonal forgiveness.36 Forgiveness is also sometimes seen as a remedy for sin and a way to restore moral order.37

Some people may initially think they can never be forgiven. With time and the weight of one’s experiences, the impossibility of forgiveness can become so ingrained that it becomes a core belief. These core beliefs set up a vicious circle of thoughts and feelings, in which people and places and events from the past are continuously brought forward into the present. Anger and resentment become the steady diet for the tormented self that feels forever powerless over experienced injustices. These relived experiences drive the person into a deep isolation where the self becomes less human—a thing, an object. This experience of losing oneself proves excruciating and often leads to contemplation of suicide as a way to resolve anguish.

### Hope emerges

Pastoral care services provide a means to reframe one’s core beliefs, manage and resolve the burden of guilt, and uncover new motivation for living.

The practice of spiritual direction within the discipline of pastoral care listens for these inner movements and encourages the person to give voice to them in his or her own words. No longer limited by a diminished, tormented self, the real self begins to relate to another reality that changes his or her identity, relieves the burden of guilt, and gives reason, purpose, and meaning to life.

Even with this opportunity for a new life, however, cognitive distortions based on a dis-proportional “faith-based prism” may persist. In this case, clinicians and chaplains must work closely together to reframe old under-standings of self and incorrect understandings of religion and spirituality into one that continues to reinforce this newfound sense of hope.38

## A VETERAN OF IRAQ WITH SUICIDE IDEATION

The following case illustrates how clinicians and chaplains may be able to work together to help facilitate the resolution of guilt.

A veteran who had served in Iraq had entered the Domiciliary Care Program at a US Department of Veterans Affairs medical center. He reported experiencing problems with guilt, forgiveness, and suicide ideation. A clinical therapeutic program was prescribed after a psychological evaluation uncovered that he was also struggling with depression and posttraumatic stress disorder.

His mental healthcare providers recognized the importance of incorporating a religious-spiritual component into the therapeutic plan, and so consulted with a chaplain to plan a suitable course of action. Specifically, this veteran reported feeling that he could not be forgiven for his military experiences, a feeling that was giving way to alienation and isolation from the God of his faith tradition.

The chaplain helped this veteran reflect on his military experiences, giving him the perspective he needed to view his God as one who truly loves him. He recognized instances in which he could have lost his life had it not been for others who intervened on his behalf at just the right time. This awareness caused him to think about his life differently, challenging him to reframe his relationship with God. Instead of simple coincidences, the veteran began to consider the mystery behind these times and places.

Over time and in keeping with the tenets of his faith tradition, the veteran stated that he was ultimately able to accept and receive God’s love and forgiveness. He now reports that these inner spiritual movements serve as a source of support during occasional relapses into emotional distress. These movements allow him to consider the mystery of his present life and its value based on his experience of his God’s love and forgiveness.

## CARE FOR SUICIDE SURVIVORS

The experience of guilt is not limited to veterans. Those bereaved by suicide are also left to manage their own experiences of the loss and ensuing complex emotions. Friends and loved ones who survive a suicide decedent may experience guilt, feeling that they somehow contributed to or failed to prevent the suicide. Such feelings of guilt are hypothesized to lower the threshold for suicidal behavior in those bereaved.39

Guilt and shame are also frequently encountered in survivors of nonfatal suicide attempts.40 Chaplaincy services might also prove useful for these individuals.

## TIME IS EVERYTHING

Patients who may have an active psychopathology should have their clinical therapeutic needs attended to first. If the clinician deems pastoral care services to be an appropriate complementary support option, care should be taken to select a pastoral care provider who is adequately prepared for this role. Different professional organizations (eg, Association of Professional Chaplains) have established board-certification procedures, minimum education requirements, and supervised practical experience required for chaplaincy certification.

Also, spiritual growth and development remain a core focus of pastoral practice. Clinicians should discontinue any collaboration with pastoral care providers who question an individual’s faith or commitment to his or her faith, or who promote thinking or actions that could be deleterious to the patient’s therapeutic trajectory.

## SUMMING UP

We have here presented our perspectives on how chaplaincy services can be used to complement clinical services in support of at-risk veterans struggling with experiences of guilt. Unfortunately, the current level of collaboration between chaplains and clinicians in sup-port of at-risk veteran populations is limited.20 Our hope is that clinicians managing these at-risk patients will develop a greater awareness of how chaplaincy services might be able to help in alleviating experiences of guilt in at-risk veteran populations. A further hope is that such cases will serve as an opportunity for greater interdisciplinary collaboration, benefiting at-risk veterans most in need of support.

## ACKNOWLEDGMENT

Dr. Rasmussen was supported by the Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment, US Department of Veterans Affairs, VISN 2 Center of Excellence for Suicide Prevention.

## Footnotes

*   This work was funded in part by the US Department of Veterans Affairs, VISN 2 Center of Excellence for Suicide Prevention, Canandaigua, NY.

*   The views expressed are those of the authors and do not reflect the official policy or position of the US Department of Veterans Affairs or the US government.

*   Copyright © 2016 The Cleveland Clinic Foundation. All Rights Reserved.

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