This month’s post is from Ken Pope’s listserv, where he kindly provides daily summaries of current articles in the field. The article is as follows:
*JAMA: Internal Medicine* has scheduled an article for publication in a future issue: “Shame and Blame in the Therapeutic Relationship.”
PLEASE NOTE: As usual, I’ll include both the author’s email address (for requesting electronic reprints) and a link to the complete article at the end below.
The author is Ami Schattner, MD.
Here are some excerpts:
When my dear secretary of many years did not show up at her desk in the hospital at 7 am sharp as usual, I was ill at ease at once. It was distinctly unusual. When time passed and she did not call and could not be reached over her cell phone, I knew that something was very wrong.
When we met again, at 7 am on the next day, she was back at work, but not really there. She told me in tears that her youngest son had an accident. Apparently, he went riding on his father’s all-terrain vehicle without permission or any experience. He overturned in the dunes on his first experiment, sustaining cervical vertebral fractures. He had undergone surgery, but no one could tell at present what the outcome would be.
As days, then weeks, and months passed, the picture became clearer, but it was too sad to contemplate. I visited him several times and often talked with his mother for hours, but what could I say? “It could have been worse…,” or “you are getting better by the day…”–the usual rhetoric sounded so vain when in fact he remained hemiparetic, dependent on his family, and in severe neuritic pain, requiring opiates and medical cannabis for some relief.
Talking to the boy I felt his shame at having brought all this upon himself–his life derailed forever–and upon his family. He was also angry–at himself, at his predicament, and sometimes at his physicians. On many days he was overcome by dark depression. These feelings not only drained his remaining quality of life but also left his physicians and physical therapists frustrated, since he was barely cooperating in his own rehabilitation.
Months, then years dragged on. The once promising scholar and athlete resigned himself to mere existence, more or less, much below his potential, even after the tragic injury.
My involvement in my secretary’s son misfortune made me reflect time and again on its deep implications.
First, I began to see it in a broader context: injuries may be “self-inflicted,” needless, and totally preventable, but so are many illnesses–although their “fuse” is much longer, taking many years, not minutes, for the damage to evolve. This applies to the myriad pulmonary, arterial, and neoplastic complications of smoking; to the metabolic disarray culminating in the escalating morbidity and mortality associated with overeating and obesity; to carelessness culminating in the acquisition of human immunodeficiency virus (HIV) infection; and many other behaviors by which, against all common sense, patients knowingly and willfully bring about their own misery. All these conditions seem to share a triad of awareness, choice, and preventability. Thus, the link between misdeed and disease or injury (ie, the risk) is clear and evident to the patient by common wisdom or medical advice; nevertheless, the patient has chosen to actively adopt the risky behavior either acutely (eg, irresponsible driving) or habitually (eg, smoking); and finally, had it not been for the patient’s own choice, the adverse outcome would not have occurred.
Second, the patient’s own role in his or her predicament is usually evident to the people surrounding the patient and to the patient’s family, and is frequently associated with significant widespread stigmatization. For example, patients with lung cancer report greater distress than other patients with cancer and many strongly feel the impact of stigma–a negative label by society associated with being held responsible for the disease.1 The resulting shame can be extremely painful and affect “core” life issues2 as well as interaction with health care professionals (eg, clinicians, nurses, physiotherapists). Similar suffering had been mapped for patients with obesity3 and other studied examples, notably, HIV infection. Thus, the patient’s attempt to recover some of his previous health is severely hampered by stigma that is left unspoken but must be highly disruptive to the patient. Feelings of guilt, remorse, and shame in the knowledge that his or her life derailed, forever causing much anguish to the family, may prevail. They may lead to self-depreciation, depression, and impaired ability to cooperate in the treatment and rehabilitation program and withstand the day-to-day pain, hardship, and uncertainty involved in trying to regain former health.
Third, I began to appreciate that physicians are not immune to stigma, and the fact that their patient brought it all upon himself (or herself), despite being fully aware of the almost inevitable consequences of their risk-taking, likely affects their attitude, possibly even their decisions.
[The physician-patient relationship] requires full commitment providing information, empathy, and bonding obligatory for patient-centeredness, patient satisfaction, trust, and adherence which translate into “hard” health outcomes.4,5 Because clinical care is strongly dependent on this human interaction, it is also susceptible to inherent biases (mostly unintentional) that are one major cause of variation in care.6 In this context, providers’ reactions to certain patients may involve negative feelings adversely affecting the degree of effort invested in their care, diagnostic accuracy, treatment decisions, and level of communication, empathy and support.6,7 Stigmatized patients may get different (less than optimal) care, just as “nice” patients may be preferred and receive better care.6 Instead of empathy and bonding, which have a positive impact on outcomes, censure, absent compassion, diminished bonding, and poor support toward patients who caused their own wretched state are likely, as well as actual variation in care, all compromising patient outcomes. For example, poor provider’s empathy and bonding on the part of the clinician was linked to low patient adherence and may be associated with actual discrimination and rationing.3
Patients whose illness was “knowingly” self-inflicted are in a class of their own and need special attention and support. However, in contrast with their special needs and harder coping, physicians may feel detached, offering less than optimal care and support. Only reflection, mindfulness, and special conscious effort may remedy that potential remoteness at a time of maximal need. In the vast realm of self-mediated illness, often more provider support and involvement are needed, but instinctively, less may be given. Should we not consciously make an effort to correct it?
The article is online at:
IN 1992, THE LARGEST NATIONAL ASSOCIATION OF PSYCHOLOGISTS REPLACED ITS CODE OF PROFESSIONAL ETHICS WITH A CODE OF GUILD ETHICS.
Professional ethics protect the public against abuse of professional power, expertise, and practice, and hold members accountable to values beyond self-interest. Guild ethics place members’ interests above public interest, edge away from accountability, and tend to masquerade as professional ethics. A decade later, in 2002, APA revised the code again, reflecting an even more extreme commitment to guild ethics. It has disseminated, taught, and enforced that code of guild ethics for the last quarter of a century.
FULL-TEXT OF PUBLISHED ARTICLE FREE ONLINE AT:
“May I become at all times, both now and forever,
a protector for those without protection
a guide for those who have lost their way
a ship for those with oceans to cross
a bridge for those with rivers to cross
a sanctuary for those in danger
a lamp for those who need light
a place of refuge for those needing shelter
and a servant to all those in need.”
–Shantideva, 8th Century Buddhist at Nalanda University in Bihar, India
John Pullyblank, Ph.D., R.Psych.