Am J Nurs 2002 January;102(1):45
Copyright © 2002 Lippincott Williams & Wilkins
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Guilt, Shame and Religious and Spiritual Pain

Outline

• Abstract
  
• RELIGIOUS PAIN
  
• THE RESOURCING OF RELIGIOUS PAIN
  
• SPIRITUAL PAIN
  
• MEETING SPIRITUAL PAIN
  
• A FINAL WORD
  
• SUGGESTED READING
  

Abstract

Hospice care is dedicated to alleviating the pain of dying people. In addition to physical, social, and psychological pain, religious or spiritual pain can add to the struggles of many patients. Religious pain is rooted in guilt leading toward punishment and experienced as fear. It is resourced through the positive teachings of the patient's religious legacy. Spiritual pain is rooted in shame leading a patient to abandon hope in God's love. It is resourced through bringing unconditional love to the patient's sense of self-hatred and inner criticism.

DYING IS FIRST and foremost a spiritual experience. While this statement is an obvious opinion, it nevertheless appears to hold among those who provide daily care for the dying. Nurses, nursing assistants, volunteers, and family members all can testify to the important role that religion plays among dying patients. In my years of work as a hospice chaplain, it certainly stands true.

Since the earliest years of the hospice movement in the United States, interdisciplinary teams have been dedicated to a holistic approach to patient care. Along with alleviating physical, emotional, and spiritual pain, hospice teams have stood together in addressing religious and spiritual pain. Unfortunately, there has been a profound lack of clarity in understanding this concern.

When I first began dialoging over the job description of a hospice chaplain, I found myself unclear about the role. It was apparent that the chaplain was an important addition to the interdisciplinary team, however, it was equally certain that no one was quite sure about what was to be done. Medicare had placed a requirement in its conditions for certification, and a chaplain was necessary. What he or she did was a bit more confusing.

In one of my earliest team meetings, the hospice director asked me if I felt a patient was in “religious pain.” I remember thinking that I had no idea what religious pain was, to say nothing of knowing if a patient was “in” it or not. Following that meeting I raced to the library to learn all I could about religious pain, only to discover that if anything was written about the subject, it must be a secret document. Religious pain remained a mystery to me. Obviously I had my own ideas, but most of them focused on the problems an individual has with God. Perhaps religious pain meant a patient was angry with God, or had difficulty praying. I wondered if family members felt cheated by the potential loss of a husband or father, blaming their powerlessness on God.

Several weeks into my investigation of religious pain, the hospice director again approached me to discuss a patient's emotional struggles. This time the question was worded differently, “Do you think this patient is in ‘spiritual pain’?” Scurrying to the library, I discovered as little information on spiritual pain as I had previously found on religious pain. This presented me with two terms with two different dynamics.

Over the next few years, I spoke with many religious professionals regarding their definitions of religious and spiritual pain. The common denominator I soon discovered was that the terms were used frequently with little comprehension of what they meant. The “condition” of religious or spiritual pain was as vague as a conversation about the meaning of forgiveness. Helping people in religious pain was somewhat akin to helping someone learn how to love. It sounded positive and important; the problem was that religious and spiritual pain remained a mystery.

After struggling with this issue for some time, I received a telephone call from the husband of a patient. He asked me to visit his wife, an 83-year-old woman with ovarian cancer. I was somewhat surprised since I knew that her pastor visited with her at least two times a week, and she had dismissed me in our earlier meetings.

“I guess you're wondering why I asked to see you,” she said to me from her hospital bed.

“Oh I supposed you had just been missing me,” I told her.

She smiled and then said, “Well the reason I wanted to talk to you was that I have a question to ask you, and I'm too embarrassed to ask my pastor.” I kept still, and she continued. “Putting it simply, I guess I wanted to know if you think I'm going to go to heaven?”

I'm not sure if my face showed my surprise but I quickly said, “Where did that question come from?”

She was silent for a moment and then said, “I was looking at my old family scrapbook yesterday and came across some photos of my Aunt Ellen. She was my mother's sister. Well, anyway, I was thinking back to a time when I was a girl and we went to visit Aunt Ellen, my mother and me.”

She stopped talking for another minute and then went on, “I guess this is where some of the embarrassment comes in. While my mother and Aunt Ellen were having coffee in the kitchen, I went into Aunt Ellen's bedroom and was looking through her drawers in her nightstand.” She took one or two deep breaths. “And I took a fifty-cent piece out of her bottom drawer.” She looked at me for my reaction. “There were five or six of them laying in the bottom of the drawer and I took one.” She started to cry, “I stole money from my aunt.”

“You must have been very young,” I offered.

“Well, I was around 7, I think,” she said, “but that doesn't change the fact that I stole money. It's one of the Ten Commandments you know.”

“Yes, I know,” I replied.

“That's why I was wondering about heaven.” She started to cry again. “God must be terribly disappointed in me, and I wonder what He'll do to me after I die. My grandmother was a seamstress and she told me that if you sew on Sunday, you have to take the stitches out with your nose after you die. If that's what happens when you sew on Sunday, what do they do to you if you're a thief? I'm so afraid!”

RELIGIOUS PAIN
It was after this conversation that I began to see a pattern in many of my patients. A connection seemed to emerge between guilt and fear, and a patient's religious dogmas or creeds. Most definitions of religion incorporate phrases such as a “set of values,” or a “moral code,” indicating some type of guidance system for life. It is against these codes, dogmas, or creeds that patients tend to measure their lives. Since many patients have an enormous amount of time for thinking, it is not unusual for a life review to occur that considers past decisions, actions, and behaviors. Seldom does a patient emerge from such self-evaluations unscathed.

In the above example, the patient was examining a childhood event against the moral code of her religious tradition. Unfortunately, once a patient starts to travel down that road, guilt and fear quickly surface. Rarely does an interior court get called to order where the defendant is found innocent. Coupled with the power of family and religious legacies, patients find themselves sinking into a pit of guilt from which there seems little hope of escape.

Religious pain, then, is a condition in which a patient is feeling guilty over the violation of the moral codes and values of his or her religious tradition. Sometimes this condition rests with perceived major transgressions such as abortion, adultery, or overt cruelty. Other times, religious pain emerges from much “lighter” infractions such as not seeking a second opinion, or failing to take better care of one's self. Regardless, patients in religious pain believe that God is keenly disappointed in their past or present behaviors, actions, or thoughts.

It is important for health care professionals to recognize that religious pain does not have to make sense in order for a patient to experience it. Religious pain is highly personal and deeply subjective. Although it springs from the patient's religious traditions and values, religious pain is always an interpretation of that belief. It is the patient's personal judgments weighed against the dogmas and creeds of his or her religious history and legacy.

Sadly, guilt is not content to stand alone within the mind of the patient. In most people, guilt asks for, and therefore always receives, punishment. Such a fact is well known by patients everywhere. It has been experienced throughout life and especially during childhood days. “Wait until your father comes home and then you'll get it,” gets translated into “Wait until you die and God gets His hands on you for your transgression, then you'll really get it.” Is it any wonder that the primary emotion of religious pain is fear? In anticipation of punishment, and rooted in guilt, the patient lies in deep anxiety for the moment of reckoning.

While this may smack of fundamentalism and its teaching on the fear of hell for sins untold, religious pain in most patients is far subtler. It roots in unexplored early childhood teachings attributed to issues of authority. Faced with death and all of its ramifications and fears, the notion of religious pain only adds to the mandate of the interdisciplinary team.

In my experience, some patients foster a belief that future punishment can be avoided if enough self-pain is administered in the here and now. Many people believe that it is better to suffer in the present before God gets His hands on them. I have worked with patients who refused pain medication with the belief that suffering now will make a difference with God in the future.

THE RESOURCING OF RELIGIOUS PAIN
During the dying process, many patients return to the religious legacies of their childhood. A 70-year-old man may be a current member of an Episcopal parish. However, when his religious trail is followed, one finds that he was raised in a Presbyterian family, but attended a United Church of Christ parish while in college. After marriage he joined his wife's Baptist church, but the family started visiting an Episcopal parish since it was the closest to their suburban home. Faced with dying, he may find himself returning to the religious legacies of his Presbyterian roots.

Perhaps people return to their childhood religious legacies at the time of dying since for many it was the first time they heard about death. In their childhood, a pet or grandparent may have died, and the religious teachings regarding death and afterlife were presented. In the Christian tradition, it may have been the first time they heard about resurrection or heaven. For many, the first concept of a funeral, with all of its mysteries and values, appeared in childhood. These early experiences impact with a depth at an emotional level, often emerging during the dying process.

In the resourcing of religious pain, the examination of the patient's religious legacy becomes critical. Since guilt is central to the patient's religious pain, the concept of forgiveness as experienced in his or her tradition is a central theme to be explored. Every major religion of the world has a formula for “cleansing”; therefore, when a patient expresses guilt for past violations of dogmas or moral codes, the religious professional needs to bring the teachings of the childhood legacies to address the issue. In particular, the patient's own beliefs regarding guilt and forgiveness need to be fully explored, searching for the ways in which redemption can be brought to the presenting difficulty.

It needs to be said here that each helper must constantly be aware of keeping his or her own religious concepts aside. Patients do not need to be confused with myriad theologies regarding forgiveness. The simplest and most helpful way to lead a patient away from guilt and punishment is with his or her own religious legacies. For a patient with childhood legacies in the Methodist religion, for example, seek the assistance of a trained professional with a background in the teachings of that denomination. In Judaism, have a clear understanding of the patient's roots and then call for assistance.

When met with the rituals, teachings, and creeds of each individual's religious legacies, religious pain diminishes greatly. It is not through conversions or evangelical fervor that most patients receive relief; instead, a simple process of forgiveness leads them out of the pit of punishment and into a more positive, hopeful view of the transition into death.

SPIRITUAL PAIN
In contrast to religious pain, spiritual pain is a much more complicated issue to explore in the light of the struggles of the dying patient. Even the attempt at defining spiritual pain is difficult. While religion tends to focus on a person's set of moral codes and creeds, centering on the behavior of an individual, spirituality is about the business of a person's relationship with the source (God) of his or her life. Obviously there is a vast difference between behavior and relationship. In religious pain, behavior is measured, found lacking, and potentially leading to future punishment. Healed by forgiveness, religious tradition suggests a “way out” for this immoral or unacceptable behavior. However, when the relationship is damaged or suspect, how does a patient find a way through such pain?

To understand spiritual pain, one must explore the nature of relationship, particularly the concepts of love. Since most traditions allow for the hopeful belief in the unconditional love of God, patients may find themselves in an unfamiliar place. Although desired in every fiber of their being, patients have little or no historic experience with unconditional love. The world does not operate in an unconditional fashion, and most people are strangers to love without strings.

Children tend to grow up accompanied by two major needs. One is the wish to do whatever they want, whenever they so choose. The other is the desire to be absolutely loved by parents and other authority figures in their lives. It does not take long in childhood development for these two forces to clash. One cannot always do what he or she wishes and still receive the needed approval of mom and dad. It is at this point that tradeoffs occur, and children decide daily whether to risk the approval of parents in exchange for their latest desire or whim. When the desire wins out, the chastisement begins. Unfortunately, when children feel this disapproval of parents they leap to certain powerful conclusions about themselves, the most prevalent being “I am a bad person,” or “Something is wrong with me.”

Children with such legacy conclusions form false images about themselves, out of which a certain “mask” self gets born. An “idealized self-image” becomes the personality presented to the world in an intense attempt to receive approval by showing others what the child believes needs to be seen. Love is sought through pretense, and over a period of years a natural confusion emerges as the child struggles to determine his or her “real” self in contrast to the mask self. Sadly, even though confused, the child is keenly aware of his or her falseness in certain areas of life.

It is in this area that one can begin to understand the power of shame in life. Throughout life, many people hide their true feelings and thoughts in a frantic attempt to be loved. Many times these pretenses are successful, and no one uncovers the hidden self. However, from time to time, the mask drops, either through life's circumstances or a careless mistake, and the real self is seen, if only for a moment. It is during such unmasking that shame is born, a condition in which a person feels fully seen and exposed. As the idealized self-image presented to the world in exchange for love is dropped, shame rushes in with a force and power all of its own. Shamed individuals speak of feeling “found out” or “exposed,” praying for the ground to open and swallow them whole. The need to hide is intense.

In the Old Testament story of Adam and Eve, after disobeying God and eating the forbidden fruit, they discover they are naked. The Bible suggests that in their “nakedness,” they were ashamed. Continuing, the story says that God went for a walk in the evening through the garden but could not find Adam and Eve. Calling out to them they admitted their nakedness, which drove them to cover up. In the coolness of the night they hid from God. In my experience, people in shame hide from love (God).

An exploration of shame is critical in an understanding of spiritual pain. Since shame is born out of an exposed, apparently unworthy and damaged self, people in shame hide from attempts to love and provide nurturing and hope. The word apparently is used since shame had little to do with the truthfulness of conclusions about the self, and everything to do with the perceptions of the individual in his or her self-judgments.

Religious pain is rooted in guilt leading to potential punishment while spiritual pain is grounded in the emotion of shame, with all of its potentially harmful consequences. Patients in spiritual pain are those who have concluded, through their own self-judgments, that there is something wrong with them at their core. Often words like “damaged goods” or “a mistake” are used in the patient's description of the self. While guilt often says, “I made a mistake,” shame suggests that, “I am a mistake.”

Having struggled a lifetime in an attempt to hide the damage, patients in spiritual pain, now approaching death and a possible day of reckoning, find themselves terrified of divine exposure. The fear is that God will not see what has been so successfully hidden from all other relationships for decades. Obviously the results of being exposed to God's eyes will be horrendous.

Bill was a 62-year-old man with lung cancer. Along with the anticipated difficulties in breathing, he struggled with enormous anxiety, seemingly unrelated to his prognosis. At times he would say, “I can't wait to escape this world.” His nurse reported to the hospice team his emotional difficulties, and psychiatric drugs were prescribed. Although they tended to mask his fear somewhat, he still expressed great anxiety over “something” he could not name.

As I met with him for the first time, we began to explore his childhood religious legacies. Born in the Midwest, Bill had been raised in a Baptist church. His record indicated that he was not a member of any particular tradition at this time, although he had been exploring Buddhism. In my first conversation with him he spoke of his homosexuality, sharing that he had lived with the same partner for over a quarter of a century. Bill talked tenderly of his love for his partner, often sharing stories of how he was now caring for Bill's physical needs.

In future meetings, it became apparent that although Bill had been quite comfortable in his gay lifestyle, he had avoided “coming out” with his own family throughout his life. Over the years, when his parents came to visit from the Midwest, his partner would move out for 1 or 2 weeks, successfully hiding Bill's homosexuality. When going back “home,” Bill had always traveled by himself. No one in his legacy history knew of his orientation. In one session, Bill told me that in his childhood church, homosexuality was one sin below murder but just an inch above child abuse. “I wouldn't be welcome back in my home church,” he told me.

It was obvious from our conversations that Bill carried a great deal of guilt for his homosexual lifestyle. While emotionally coming to grips with it at one level, he had never been able to stand up and be who he truly was. He was, in psychological terms, unable to individuate. As we explored his guilt, Bill wrestled with an enormous demon. If he asked God to forgive him for his “sin,” as identified in his childhood religious teachings, would such a confession obliterate all of the love and joy of his relationship of the past 25 years? Could he ask forgiveness for a “sin” which he did not identify as sinful?

Eventually we were able to explore the possibility of asking God to forgive him for any ways in which he had abandoned his faith, realizing that there were many different meanings to such a prayer. Bill held on to the notion that he would be forgiven any sin if he offered a general confession. It seemed to work for him, and he prayed daily for forgiveness.

While there was some relief, Bill soon became more anxious. One day he told me, “You know, I know that God forgives sins and loves everyone—it says so in the Bible—but if God knew me the way I know me, it would be a different story.” At that moment Bill was putting into words the concept of spiritual pain. He was expressing the fact that his attempt to hide his “sins” from others had been extended to a successful deception of God. With his impending death, Bill's mask would be torn off and God would see him in all of his “nakedness.” This concept sent Bill into a renewed sense of terror. The fear of being found out by his parents, hometown people, pastors, and teachers was now extended to God.

The following day when I visited with Bill, he turned his face away from me toward the wall. “I don't need any help from anybody,” he said. His partner told me that Bill would not allow him to rub his back or even to hold his hand. Bill was in the early stages of “hiding” from Love for the fear of being seen as “damaged” or “bad.” He was in spiritual pain. Several days later Bill died, sitting up in his favorite chair with his eyes open. He had told his partner that he believed if he did not shut his eyes, he would not die. Sadly, his fear overpowered him toward the end of his life.

MEETING SPIRITUAL PAIN
Unlike religious pain, spiritual pain is not responsive to a formula, creed, or doctrine. There is no mandate within tradition for the releasing of spiritual pain. It is a self-imposed exile from divine love and emerges from legacies of self-criticism and harsh judgments. Rooted in shame, spiritual pain sees only an unmasking by God, an occurrence that coincides with death. While Bill was somewhat successful in his attempt to feel forgiven by God for the “sins” of his life, he was unable to feel acceptable to God since he was unacceptable to himself, a fact given power by his unwillingness to be authentic within his family system.

It is virtually impossible to accept the unconditional love of God while at the same time imposing self-judgments of the most severe kind. When the inner critic of a patient's life claims that he or she is unlovable, as evidenced by living a “hidden” life, opening to the love of God seems incredulous. The old statement “If you don't love yourself, you will not be able to love others,” is only partially accurate. The fact is that if one does not love oneself, one will never trust the love of another. Since Bill knew that he was damaged goods, and testified to that belief each time he hid his true self from his family, how could he possibly believe that God would think otherwise? We assume that God thinks the same thing we do.

Resourcing spiritual pain thus becomes a matter of convincing a patient that he or she is a lovable person, despite any and all inner thoughts to the contrary. The healing only can occur when unconditional love is allowed to enter into a self that had previously wallowed in self-criticism or self-hatred. Obviously this is a difficult task, both for the patient and the health care professional. To bring love and acceptance into a life that has previously felt unlovable is a major challenge. In the truest sense, it is my conviction that everyone is in spiritual pain to a greater or lesser degree. Healing, unfortunately, is the work of decades for most people. The average length of enrollment before death, for most hospice patients, is a little less than a month.

The question remains: How can one bring unconditional love to patients who are living, and dying, in shame? As I have worked with this issue over many years, I have discovered that love is suspect for many patients. I get paid to visit and offer my words of help and solace. The nurse is a salaried professional, paid to visit and provide care, as is the nursing assistant. On the other hand, the volunteer is visiting out of desire. There are no strings attached, no monies paid, and most volunteers are in the home, or at the hospital bedside, because they choose to be present. This, in itself, can feel miraculous to a patient. Someone sees enough worth in the patient to stand beside him or her without coercion or salary. The hospital orderly who stops his or her busy tasks to genuinely inquire about the patient's condition brings worth to the patient. A newspaper delivery person who stops on the porch and says, “How are you doing today, Mr. Smith?” means more than a dozen visits from a paid professional.

Bringing unconditional love to a patient who believes only in conditional acceptance is the major way to break down the walls of spiritual pain. While it is only a start, it can make a profound difference nevertheless. Most patients have found their way into spiritual pain decades earlier through harsh inner criticism. Hospice workers know that the dysfunction of years cannot be turned around in a few short weeks; however, love can be brought to each patient with the hope of offering some relief to the fears that focus on God's disappointment.

I often define spiritual pain as “the felt absence of the ever-present God.” Patients, in their attempts to hide from God's disapproving eyes, obviously feel His absence. It is impossible to hide from God in one area and not feel His absence everywhere. Spiritual pain, then, leads to an absence of joy, hope, and future possibility of divine union. It is always self-imposed, making it extremely difficult to heal. Nevertheless, the hospice worker has no choice but to bring unconditional love to the patient and family in every possible way. Each time a patient wonders about the possibility of his or her self-worth, love will push the potential of healing one step further toward hope and joy.

A FINAL WORD
In this brief article I have tried to divide religious pain from spiritual pain. While I am very much aware that many religious traditions do not separate religion from spirituality, for the purpose of clarity I have found it helpful. Religious and spiritual pain both point to the powerful realization that one's personal psychology cannot be separated from one's religious and spiritual path. Self-esteem does indeed affect the ways people experience God. Guilt, from a psychological perspective, is a block to freedom. It calls forth the need for a doctrine of forgiveness, mostly available from a spiritual dimension.

Also, I am painfully aware that journal articles are generally scholarly pieces filled with footnotes and quotations. This article is not. Certainly the years of study, conferences, books, and personal experience have brought me to the conclusions in these few pages. Therefore, I have listed some suggested reading of works that have helped me grow in my understanding of spiritual and religious pain.

Ultimately both religious and spiritual pain leave a patient in enormous fear. It is my hope that the easy road of psychiatric drugs will only be taken as a last resort. Masking a patient's religious pain prior to his or her opportunity to attempt to work through the many painful issues of guilt leaves a patient to die without the healing for which hospice stands. Attempting to use words to reassure a patient dying in self-hatred will never be successful. Along with the dedication to alleviate pain, the interdisciplinary team needs to proclaim love to all as the deepest gift they have to offer.

SUGGESTED READING
Anderson AC. The Problem Is God—The Selection and Care of Your Personal God. Walpole, NH: Stillpoint Publishing; 1984.

Barks C, trans. The Essential Rumi. New York: Harper Collins; 1995.

Bertman S. Facing Death—Images, Insights, and Interventions. New York: Hemisphere Publishing Corp; 1991.

Bly R. What Have I Ever Lost by Dying? New York: Harper Collins; 1992.

Cohen A. The Dragon Doesn't Live Here Anymore—Loving Fully, Loving Freely. Somerset, NJ: Alan Cohen Publications; 1990.

Colegrave S. By Way of Pain—A Passage into Self. Rochester, VT: Park Street Press; 1988.

Dass R. Journey of Awakening—A Meditator's Guidebook. New York: Bantam Books; 1985.

Fleming U, ed. Meister Eckhart—The Man from Whom God Nothing Hid. Springfield, IL: Templegate Publishers; 1988.

Fremantle F, Trungpa C, trans. The Tibetan Book of the Dead. Boston: Shambhala Publications; 1975.

Guntzelman J. Blessed Grieving—Reflections of Life's Losses. Winona, MN: Saint Mary's Press, Christian Brothers Publications; 1992.

Jampolsky L. The Art of Trust—Healing Your Heart and Opening Your Mind. Berkeley, CA: Celestial Arts; 1994.

Kornfield J. A Path with Heart. New York: Bantam Books; 1993.

Kubler-Ross E. On Life after Death. Berkeley, CA: Celestial Arts; 1991.

Levine S. Who Dies? Garden City, NY: Anchor Press Doubleday; 1984.

Levine S. Healing into Life and Death. Garden City, NY: Anchor Press Doubleday; 1987.

Menten T. Gentle Closings—How To Say Goodbye to Someone You Love. Philadelphia: Running Press; 1991.

Mitchell S. The Enlightened Heart—An Anthology of Sacred Poetry. New York: Harper & Row; 1989.

Nisker W. Crazy Wisdom. Berkeley, CA: Ten Speed Press; 1990.

Rajneesh B. The Book of the Secrets. New York: Harper & Row; 1976.

Rinpoche S. The Tibetan Book of Living and Dying. San Francisco, CA: Harper; 1992.

Rodegast P, Stanton J, compilers. Emmanuel's Book. New York: Bantam Books; 1987.

Satterly L. Tattooed in the Cradle—The Healing Journey from Family to Spiritual Wholeness. Maple Glen, PA: The SEARCH Foundation; 1993.

Starr J, ed. Two Suns Rising—An Anthology of Eastern and Western Mystical Writings. New York: Bantam Books; 1992.

Yancey P. Where Is God When It Hurts? Grand Rapids, MI: Zondervan Publishing House; 1977.

Zukav G. The Seat of the Soul. New York: Simon & Schuster; 1989.

Key words: fear; forgiveness; guilt; punishment; religious legacy; religious pain; shame; spiritual pain; unconditional love

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