Harpham, Wendy S. MD
WENDY S. HARPHAM, MD
Every day, you see newly diagnosed patients whose past choices possibly (or likely) contributed to their current health crisis. Maybe they smoked, neglected screenings, or follow-up exams, or ignored a growing lump for years before seeking medical attention for their now advanced cancer.
For some of those patients, a cloud of guilt (often seeded with shame, embarrassment, or anger) rains over them, dampening their ability to cope. Even if able to make wise decisions and comply with therapy, they may hide discomforts or refuse support, feeling responsible for their poor prognosis and believing they deserve to hurt. A fog of regret can obscure opportunities for meaningful connection and joy, exacerbating patients' isolation and increasing their risk of depression.
While some patients signal their distress with anything from mumbled side comments to brash jokes about causing the mess they're in, others suffer silently. Whatever the case, patients troubled by guilt need help.
Any discussion of guilt strays into philosophical and spiritual spheres outside the realm of clinical medicine. Even so, you may play a useful—and occasionally vital—role in guiding patients to healthy responses, beginning by considering whether guilt is serving or inhibiting patients' progress.
Guilt and shame can energize patients like hot coals under bare toes. If mobilizing them positively to, say, quit smoking or handle tough treatments, you can reinforce that “It's good to feel guilty when it's helping you.”
But if guilt is just making a bad situation worse, your offering the notion of letting go may be the key to helping them. Try stating the obvious, because even if they've already heard it from loved ones, they may hear it differently when coming with authority from you: “You can't change the past, so feeling bad about it won't help anyone in any way. You simply have to let it go.”
Unfortunately for some patients, “letting go” is anything but simple. They're thinking: “How can I let it go when every day I see my spouse being run ragged . . . the bills piling up . . . my children struggling? This is all my fault.”
For those patients, try introducing a new way of thinking about their past choices, such as focusing on intention: “If you intended to get sick and use your illness to hurt others, it would be a different matter. Everyone knows you didn't want this cancer and never wanted to hurt anyone. So it's okay to let it go.”
In addition, you can frame “letting go” as an empowering choice: “It's time to let go of the past so you can direct all your energy to dealing with what's happening now. Choosing to let go is a healthy response to worries about the past—and it's the best way you can help those who care for and about you.”
If you sense that a dose of practical philosophy might work, talk about how “We all live life forward, not backward. When faced with problems, it helps to reflect back briefly, looking for insights that help us take proper action from now on—but if, and only if, we keep it brief. Ongoing regret about what's over and done only hurts us by tethering us to the past, keeping us from seeing and embracing all the good in front of us. To move forward, we have to let go of guilt and regret.”
What about telling patients to forgive themselves? I've known patients who struggled with guilt and for whom the act of forgiving was essential to ultimately dealing with their new reality. Especially for those diagnosed with terminal disease, forgiveness quickly paved the way to peace and comfort.
As I see it, despite the great healing potential of forgiveness, in general I'd avoid bringing it up in clinical settings. The power and baggage of the word “forgiveness” invoke complicated ethical and spiritual issues. After all, what does it mean to forgive oneself for causing pain to loved ones? And how does one forgive causing one's own pain? The complexity and delicacy of these topics takes the kind of time most clinicians don't have.
This problem of time pales in comparison to the possible harm to clinician-patient bonds. Your introducing forgiveness, with its subtext of right and wrong, may rattle patients' confidence in you as a judgment-free advocate and caregiver, even if only subconsciously.
It's a risk you don't have to take because, without mentioning forgiveness (or in response to patients who ask, “How can I forgive myself?”), you can push patients to benefit from the services of other professionals, explaining: “Just as I'd prescribe treatment if you had difficulty eating or sleeping, I'm prescribing a consultation with a specialist trained to help you let go of worries about the past.” Then, with one or two questions, you or your staff can tailor your recommendation, guiding your patients to see a psychologist, psychiatrist, social worker, chaplain, or other spiritual leader.
After a cancer diagnosis, patients must muster all their resources to make wise decisions and cope with the unwanted changes, losses, stresses, and pain. Compassionate care of patients troubled by guilt involves recognizing and acknowledging their distress, and helping them let go of worries about the past.
More than just providing comfort, your efforts may be essential to patients getting good care today and living as fully as possible in whatever time they have left.