Friday, July 10, 2015

Guilt’s Unacknowledged Role in Mental Health

(Masaccio Fresco image from the 
Cappella Brancacci, Santa Maria 
del Carmine,  Firenze, Italia
provided via Wikimedia Commons  
[Public domain].)
Guilt’s negative aspects go beyond its deterrence to psychological growth and development. It also affects our mental health and wellbeing. It can make us sick. Guilt is a major cause of depression, anxiety, paranoia and suicide. It is also a significant factor in less common ailments such as hypochondriasis, and other somatoform disorders. This view is not widely held among medical and mental health professionals, despite the fact that they encounter and deal with guilt daily in their practices. In the case of depression, biological and chemical imbalances or psychological factors like loss, grief and failure are emphasized. In our experience, however, these conventional viewpoints both overlook and underestimate guilt’s causal role in these serious disturbances. We have become increasingly conscious not only of the important causal role of guilt in these major psychological disorders but also of the damage it generally inflicts on our mental health and wellbeing.&nbsp

Long before The Diagnostic and Statistical Manual of Mental Disorders had been conceived, Lady Macbeth’s guilt-induced decline into mental disorder and suicide dramatically and accurately portrayed at the extreme the psychological damage that guilt can inflict on the human psyche. Despite Shakespeare’s vivid and accurate portrayal of the dangerous consequences of guilt, and despite commonsensical grounds for belief that the bard got it right, standard and conventional diagnostic criteria often overlook and underestimate the role of guilt in some of our most frequently encountered psychological difficulties. We can see this blind spot in The Diagnostic and Statistical Manual of Mental Disorders. This important manual, used worldwide by psychiatrists and psychologists to help them diagnose psychological problems, mentions guilt as a diagnostic criterion only in major depressive episodes, depressive personality disorders, and dysthymia, the latter of which being only recently added to the manual. The insignificance of guilt in the manual’s diagnostic scheme is also suggested by the fact that the word guilt is not even in the index. Nor is it listed as a contributing factor to anxiety. Guilt is certainly not generally perceived as a cause of any mental disorder. However, as therapists we can’t avoid the truth that the mere fact of diagnosing someone with a mental disorder induces guilt. Even the need to come to therapy is itself a source of guilt.


One cannot help but wonder why the manual does not stress the importance of guilt, because clerics and therapists have been seeing and dealing with guilt, one way or another, for hundreds, if not thousands, of years. Perhaps guilt’s role in mental disorders is muted because it has been viewed primarily as a religious construct. Or perhaps guilt is viewed just as a normal feeling, like grief or disappointment. Or, perhaps they view guilt primarily as a positive factor demonstrating the presence of normal conscience. Finally, they may feel guilt is mainly deserved. Normal or not, deserved or not, guilt is a potentially dangerous feeling that is a ubiquitous threat to our mental health and wellbeing. While we cannot fully explain the virtual absence of guilt’s role in the official pantheon of mental disorders, we do know it is a serious threat to mental health.

We know that the diagnosis and treatment of both physical and mental illnesses depends importantly upon naming something for what it is. Calling a spade a spade can often save us, like saying Rumpelstiltskin.(1) Many of us are aware of misdiagnoses of physical illnesses, as, for example, when someone’s edema is diagnosed initially as being caused by heart problems only to learn later that it was caused by cancer of the kidney. Similarly, we often think the cause of our psychological suffering is depression or anxiety. Later, we have often found that depression or anxiety, painful and serious as they may in themselves be, are not the primary cause of our difficulties. We often find this primary cause to be guilt. Unfortunately, guilt often hides and lurks behind these other disturbances and, for this reason, can be extremely difficult to see, at least, initially.

This is not to say that we do not take the depression symptom seriously. We must treat it with all the means at our disposal, including medication when necessary. Although we know that treating the symptom does not work over the long term (eventually we must treat the root cause), it may be necessary to treat the symptom (i.e., the depression) because the symptom might kill the patient before we get to the root cause. In that way, the treatment procedure is analogous to treating alcoholism. Drinking is a symptom of an underlying cause, but if the symptom is not treated early on, then the patient may die before the cause is found and can be treated.

Part of the explanation for our diagnostic blind spot is the way patients typically present their problems. Guilt, in our experience, is rarely the presenting problem. We suspect that if a person could articulate the problem clearly as guilt, he/she might be more likely to go to a priest or minister or rabbi. We must, however, make a point, up front, that astonished us, albeit not until we had time to reflect on it and subsequently acknowledge its truth. In all our years of practice, we have never—not once—seen a patient who was not struggling with a large reservoir of both conscious and unconscious guilt. They usually suspected that the cause of their depression and anxiety was something other than guilt. They usually suspected that the cause was an actual or impending loss, such as loss of a marriage or other important relationship, a job, their health, their drive, the meaning of their life, their youth, their reputation, their status, or something else they valued. They come to therapists because therapists are better known for dealing with these problems. Despite the fact that guilt was seldom the presenting problem, it would always eventually appear, but only after layer upon layer of “other stuff” had been removed.

While the more common presenting symptoms of anxiety and depression can be extremely painful and dangerous themselves, we can bear those painful feelings more easily and with less threat to ourselves than we can bear feelings of guilt. While there are many feelings (e.g., hate, anger, jealousy, fear) that can cause us to feel guilty, guilt itself is the only feeling that we palpably experience as indisputable evidence that we are bad, that we have somehow sinned. The thought that I am bad or evil is a threatening and sometimes annihilating experience. It suggests I am not only bad but also worthless, of zero value. The mere suggestion that we are worthless is enough to depress us and frighten us. It is simply not possible to feel a lot of guilt and a lot of self-esteem at the same time. Common sense arising from observations of commonplace life experiences confirm that guilt and self-esteem cannot compatibly share the same house. Regardless of our genetic make-up, it is difficult to imagine someone feeling a lot of guilt without feeling a lot of depression and anxiety. To one degree or another guilt devalues our worth and diminishes our feelings of wellbeing.

Guilt can actually make us hate ourselves, and at its worst, can cause us to give up on ourselves and consider or commit suicide. In an ironic twist that adds to the complexity of guilt, suicidal thoughts themselves can compound our feelings of guilt, because suicide is a sin in the minds of many. Even if there were no religious compunctions about suicide, it is usually viewed as evidence of ultimate failure to deal successfully with life.

While feelings of depression and anxiety are painful and menacing enough, they do not hit our vital spots—they attack our walls. Guilt, on the other hand, assaults our foundation, our sense of self-worth. It threatens to annihilate us. The deeper fear of experiencing ourselves as evil is a principal reason for our defenses substituting that deeper fear with a less horrific fear, such as the fear of flying or taking escalators or driving over bridges. These intense fears (of flying, escalators, bridges, and many others) offer a kind of euphemistic protection against the real fear (i.e. that I am evil or bad) that hides behind many of the phobic manifestations of anxiety disorders. It is easier to face the depression or anxiety we experience as a result of some failure, than to face the guilt we feel about the failure. The guilt suggests we are “bad” as a result of failing. To feel we are “bad” is more difficult to face than the fear we are simply incompetent or not pretty enough or handsome enough, or fast enough or diligent enough, etc.

Guilt also hides behind normal expressions of grief and the typically accompanying depression, for example, with the grief attending the death of a child or loved one. In our experience, after the grief work, guilt begins to emerge in the form of deep regrets and self-recriminations about what one did or failed to do while the loved one was alive. Many therapists encounter this phenomenon.

For all these reasons, it is difficult for us to look directly at the real source of our fear without shattering. It’s one thing to look at my fear of flying; it’s another to look at the fear of my own evil, to look my own Medusa(2) in the face. Even someone as powerful as Perseus couldn’t do that. He had to see it as a mirrored reflection in his shield. That’s why therapists mirror so that people can see their “faults,” their dark side, the parts of themselves unacceptable to authority, from a safer perspective, in reflection, as Perseus(3) did, rather than head on.

While the extreme consequences of guilt portrayed by Shakespeare do occur, we are more familiar in our daily practice with less severe cases of guilt caused by less dramatic infractions of mores, rules, and laws. It is almost impossible to imagine humans living a life free of guilt. It is also difficult to imagine humans incurring guilt without suffering (although we assume that sociopaths by definition do not suffer in this way). Therapists are not here to judge others; we are here to help others with their suffering, no matter what the cause. Many religions hold a different view, stating from their pulpits that the cure is simple—just stop sinning. Unfortunately, we are aware that often the ones speaking this “truth” cannot practice it themselves.

In years past, most people who suffered guilt, and knew it, went to their priest or minister or rabbi for help. However, some of those who turned to religion for relief from their guilt were acting like alcoholics who, after a bad hangover, turned to drink for relief, to some of the “hair of the dog that bit them.” Most religions, however, do have spiritual tools that can help people assuage their guilt even if the guilt is caused by violation of their own ideals.

Today, many people turn to therapists and analysts for relief rather than religion. Therapists, secular as they may be, would nevertheless be wise to borrow some of the spiritual tools that have long been sources of comfort for guilt. On the other hand, if the spiritual tools and religious practices had been sufficient, the practice of psychotherapy probably would not have expanded to where it is today. Many people today simply feel that religion is closer to the problem than to the solution. It is probably also true that many patients do not suspect that guilt is the real culprit behind their pain and suffering. They think their suffering is caused by something that therapists are more qualified to deal with, like anxiety and depression.

If we are to help our patients optimally, we must first name guilt for what it is—a major cause of some of our most difficult mental disorders. We must also develop and use the psychological, spiritual, and clinical tools and methods that can help us diagnose and treat guilt. One purpose of our book The Guilt Cure is to help increase awareness of guilt’s causal role in some of our most difficult psychological problems and to propose methods and approaches for treating them.

1) In the fairy tale, Rumpelstiltskin, a manikin saves a young woman’s life but makes her promise him her first child. The woman marries the king and when her first child comes, the manikin demands the child. She is distraught and the manikin takes some pity by offering to let her keep the child if she can guess the manikin’s name, which is Rumpelstiltskin. Finding his name was a torturous process but she finally did learn his name and save the child for herself. Being able to name something is an important step in diagnosis of many kinds of problems. Sometimes we save ourselves by becoming conscious enough of our problems to give them a name, like I am an alcoholic or the king is a tyrant.

2) Medusa is a mythical figure who personifies evil. She is one of three Gorgons who according to myth had wings and snaky hair, most horrible to mortals. No man can behold her and live. Whoever looked at the Medusa turned instantly to stone.

3) In the myth of Perseus, the shield given him by the goddess Pallas Athene served as a mirror that permitted him a view of Medusa sufficiently to clearly lop off her head without actually having to look directly into her face. According to the myth, Medusa’s face, when looked at directly, had the deadly power to turn the viewer to stone.

Fisher King Press publishes an eclectic mix of worthy books including Jungian Psychological Perspectives and a growing list of alternative titles.  www.fisherkingpress.com

Copyright © 2011 by Pennington, Staples, and Fisher King Press, all rights reserved. For permission to reprint this article contact Fisher King Press.

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