Saturday, July 4, 2015

Denial, Guilt, and the Mental Health System

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. 

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.