The Problem of Health-Related Shame

[J.Adderton, BSN, MSN]

We know as both patient and nurse that shame frequently occurs in healthcare. I have written openly about my alcoholism and during active alcoholism... I was the queen of shame. I sought medical help for nausea/vomiting, high blood pressure, depression, anxiety and bloody stool and never once did I reveal my problem drinking. I would greatly underestimate when answering the question "how often do you drink alcohol?" and overestimate the question "how frequently do you exercise?". Shame significantly impacts health, illness and self-care behaviors. Just think about your own experience with health-related shame to understand the powerful force shame can be when seeking healthcare. Have you ever felt as if an illness was due to a personal flaw or defect?

Researcher and author, Brene Brown Ph.D. defines shame as "the intensely painful feeling or experience of believing we are flawed and therefore unworthy of acceptance and belonging". I have often used shame and humiliation interchangeably, but there is actually a difference between the two experiences. Shame is the state of self when we believe or feel we do not "measure up". It is the painful feeling that we have fallen short of the ideals or goals we have set for ourselves. Humiliation is temporary and is a loss of self-esteem and self-respect. The source of humiliation is caused by another person through intimidation, physical and mental mistreatment. Both emotions can leave an individual feeling isolated and alone.

Health-Related Shame

Health-related shame occurs when a person seeking (or avoiding) healthcare perceives their condition as a defect or personal shortcoming. Shame is especially prevalent in individuals with conditions related to personal and lifestyle choices (i.e. obesity, hypertension, diabetes and heart disease). I have often delayed my yearly physical thinking "if I could just lose 15 lbs" before the appointment- magically thinking this would restore my comfort during the visit. With stigmatized conditions, such as obesity, diseases linked to smoking and addiction, individuals may feel as if they failed to make healthy life choices. Shame is common around behaviors such as overeating, smoking, not exercising, medication non-compliance. Individuals viewing their ailment as a defect or personal flaw are at risk for humiliation during healthcare encounters.

Behaviors Associated with Shame

There are many reactions and defenses to shame, some helpful and others harmful. Avoidance is a common reaction to shame and provides an "emotional wall" to protect the individual from exposure to humiliation. There are several ways avoidance plays out in shame, for example, not going to the doctor or not keeping follow up appointments. Excuses are made for missing appointments- "I will make the appointment once my blood pressure is better", "I need to exercise consistently for a month before I return for a follow-up appointment". Others may respond to shame with anger towards healthcare providers. Have you ever cared for a patient that makes any of the following comments:

• "The doctor only wants me to come in so he will make more money"
• "My doctor treats me like just another number"
• "That nurse is looking down on me"

I can think of past patients that I cared for that were angry and difficult and now see how the anger could be the result of underlying shame.

Consequences of Health-Related Shame

The consequences of shame have a significant impact on physical health. Shame may keep an individual from seeking healthcare. When I was in active alcoholism, I often experienced significant dehydration. As a nurse, I knew I needed a workup for dehydration but was too ashamed of my condition to seek help. When I did visit my doctor, I did not disclose the true extent of my illnesses. As a result, I was treated for various symptoms but delayed care for the underlying issue. Individuals with health-related shame may be disengaged and not participate in the plan and interventions to address the problem. Disengagement manifests in failure to return for further treatments, consultations or follow up appointments.

How Can Nurses Address Health-Related Shame?

The first step in therapeutically addressing health-related shame is to increase your awareness of patients with shame vulnerabilities. It also helps to explore your own feelings of shame and any biases you may have with specific health problems or conditions. Think back to nursing school and how to communicate therapeutically to build a nurse-patient relationship. The techniques you learned in school can be used to help patients with shame. Starting the patient encounter with a "lecture" on how the patient's actions or behaviors caused the problem will likely lead to more shame and humiliation. It is important to respect the patient and validate their feelings. In validating the patient the nurse is able to "meet the patient where they are" promote communication. The patient better maintains dignity if they acknowledge their own problems instead of being confronted early in the interaction.

Have you ever experienced shame related to nursing? There have certainly been times when a patient goal was not met and I felt I was incompetent. What do you feel is unique to the nursing profession that can be a trigger for shame?

References

Lazare, A., (1987). Shame and humiliation in the medical encounter. Archives of Internal Medicine, Vol 147, 1653-1658.

The Shame and Medicine Project www.shameandmedicineproject.comLyons, L., & Dolezal, L., (2017). Shame, stigma and medicine. Medical Humanities, 43

(4),208-2010.

[DaveICURN]

For point of fact, the English Oxford definition of shame is: 1 A painful feeling of humiliation or distress caused by the consciousness of wrong or foolish behaviour.

I only make this point as a point of distinction because I feel its important to have the most widely accepted definition for the sake of conversation.

The poster makes excellent point on the needs for therapeutic communication for the education and understanding of the patient.

To really get to the center of the issues, we need to understand the W's (Who, What, and Why) of the situation. The importance of the Pt understanding the implication of the disease process cannot be understated. However it is important not to drive the Pt away from resources available to them.

Would this plan work for every patient? Of course not. Care must be individualized for the Pt. This includes therapeutic communication and education.

However, when do we use shame to the nurses advantage? Do we not shame the family of the bed ridden Pt when we tell them about the bedsores they admit with from home? Do we not shame the family when we tell them not to press the PCA button for the Pt?

Shame is an important part of learning. It helps us tie an emotional response to the thing we wish to learn. This way we are more apt to retain the information for later use. This tool, I believe, should not be so readily abandoned. The shame felt because of an negative action is good, useful, and natural. While it's true we do not need to hound the Pt about their shortcomings, We do need to address them. There will be Pt who are resistant to education. Some will be very accepting, and the majority will be in the middle.

[J.Adderton, BSN, MSN]

Thank you for presenting another valid viewpoint. I agree- there are situations when health-related shame has the potential to be a catalyst for change. Exploring this perspective would be a good article.

[traumaRUs, MSN, APRN]

For sure I think this exists...especially among healthcare personnel.

[BeenThere2012, ASN, RN]

Thank you for this article. I can relate as both a patient and nurse. You've given me things to think about in both perspectives.

I currently work in a psych hospital and I see the anger and shame behaviors everyday. I do my best to put patients at ease when discussing their history, treatment plans etc...

When admitting a patient, I often start out with a strong statement about how I will protect their confidentiality (including of course the exceptions mandated by law), and tell them "we are not the police" and "there is no judgement here".

Although it is not considered appropriate to discuss our own personal issues with patients, sometimes I throw in "I can relate to what you are going through!" Or, " I understand how hard this can be from personal experience!" I find this helps break the ice at times and at others, it has provided a bond of sorts that I feel immediately as patients break down guards and cry or then open up and start talking more freely.

When I have been the patient and a provider does what I described, it has had a positive effect on me. One thing for example, is seeing them in a good place at that time and gives me hope for my own struggle.

As I said, I'm not sure if this is completely appropriate, but I know it has helped me in my practice. I don't disclose any details or go on talking about myself....Just saying a little "disclosure" if you will, sometimes goes a long way to building trust.

[J.Adderton, BSN, MSN]

Thanks for sharing. You work in a area with diagnosis shrouded in shame and stigma. I know it helps to connect with your patients when you are able to approach without judgment and with insight into the patient's experience.