guilt and shame in therapeutic relationships
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Patient Education and Counseling, 8 (1986) 35%365 Elsevier Scientific Publishers Ireland Ltd.
GUILT AND SHAME IN THERAPEUTIC RELATIONSHIPS
JAMES W. PICHERT* and PEGGY ELAM
Diabetes Research and Training Center, Vanderbilt University, Nashville, TN 37232 (U.S.A.)
(Received May Zlst, 1985) (Accepted April 24th, 1986)
The ethical underpinnings of patient education require health care profes- sionals to deal with patients feelings of guilt and shame since both can nega- tively affect patients adjustment to illness and adherence to medical regi- mens. These feelings, whether realistic or not, can play a role in the therapeu- tic relationship from the moment the first examination begins. This paper identifies sources of shame and guilt and suggests strategies for patient educa- tors to minimize their effects.
Key words: Guilt - Shame - Patient-provider relationship - Ethics
In April 1985, a lo-year-old girl with diabetes took her fathers pistol and shot herself in the stomach, reportedly because she felt guilty about eating part of a chocolate Easter bunny [l]. Fortunately, few people who feel guilty about real or supposed violations of a health care regimen go to such extreme behavior. The case does, however, raise ethical issues for patient educators with respect to the beneficence (inthis situation, their ability to recognize and resolve existing guilt and shame) and non-maleficence (their ability to avoid heaping unnecessary guilt or shame on their patients) of their educational services. Dr. Barnards article in this collection has already pointed to beneficence and non-maleficence as foundational in the ethics of patient edu- cation [Z]. These concepts clearly demand that patient educators prevent or minimize patients experiences with guilt and shame. This paper describes selected educational practices for doing so.
Guilt and shame, while distinguished in the psychoanalytic literature, are distinctly related [8-51. Guilt is generally considered to be self-reproach over
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07383991/86/$03.50 0 1986 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland
violations of internalized standards, whereas shame is associated with antici- pated or actual disapproval or scorn from others . For instance, someone who had decided to quit smoking might experience guilt if he succumbed to the desire to light up. He might also experience shame if a relative who wanted him to quit discovered him smoking. Our purpose, however, is not to emphasize the differences between these two reactions, but to focus on their effects and their implications for patient educators.
EFFECTS OF GUILT AND SHAME
The effects of guilt and shame can be positive or negative, apparently de- pending on whether the guilt is realistic (where the person had the ability to influence a negative outcome but did not do so), or unrealistic (where the person had no control but still feels responsible), and how the patient re- sponds. For instance, patients who believe their illness is punishment for guilty wrongdoings may become angry or enraged . If the anger is turned inward, the patient may become depressed and less responsive to treatment. If anger is channeled outward, the patient can become hostile and turn on the personnel caring for him [7,8]. Patients who feel punished may also paradoxi- cally resist medical advice as interference with the deserved punishment .
Anger is not the only concommitant of guilt and shame. Abrams and Finesinger [lo] were concerned about cancer patients guilt because of the way it seemed to affect the patients behavior. Patients who felt guilty about their illness denied symptoms and thus delayed seeking medical treatment, felt infe- rior and inadequate, and were inhibited in communicating. Those who re- proached themselves for delaying medical treatment experienced intensified feelings of guilt. Those whose feeling of guilt stimulated attitudes of inferior- ity, inadequacy, dependency, and rejection had lower self esteem and seemed unable to rehabilitate themselves [lO,ll]. Similar reports have been made about people with arthritis [ 121 and bulemia [ 131. Finally, Felton, Revenson, and Hinrichsen  found self-blame significantly related to poorer illness adjustment.
Others have argued that guilt and shame can be positive, i.e. whenever they provoke us to action. As Kushner writes, Sometimes we have caused the sorrow in our lives and ought to take responsibility.. . .A sense of our inade- quacies and failings, a recognition that we could be better people than we usually are, is one of the forces for moral growth and improvement in our society. An appropriate sense of guilt makes people try to be better [ll]. Conversely, patients who cannot or will not accept blame for illnesses over which they had control may not be willing to alter previous detrimental behavior patterns [ 151.
Finally, in some cases patients self-blame and guilt feelings may be benefi- cial to their emotional well-being. For example, a patients guilt may serve a defensive purpose by denying the intolerable conclusion that no one is respon- sible [ 161. In such cases, attempts to remove feelings of guilt may be met with anxiety . A woman presented in one study convinced herself that her
daughter had contracted leukemia from the tumors of a family pet that the mother should have had destroyed. The woman became demonstrably uneasy when a physician tried to dissuade her from her belief [ 161.
It should be noted that whether a patients guilt is realistic or unrealistic, his or her feelings of guilt or shame are always real. The next section identifies several sources of such feelings and specific strategies to prevent or alleviate them.
SOURCES OF AND STRATEGIES FOR HANDLING SHAME AND GUILT
Guilt and shame may result from any one or a combination of several influ- ences. The first, what Berger has termed iatrogenic guilt, may be caused and controlled by health professionals themselves . The next two sections of the paper suggest some of its sources and ways to control them. Guilt and shame may also result from influences outside of patient educators control (e.g. social stigmata [ 10,19,20], loss of personal independence [9,12], and reli- gious/personal values [ 111). The paper concludes with strategies for minimiz- ing the negative effects of guilt and shame from such sources.
Iatrogenic guilt Health care professionals may cause guilt by: (1) emphasizing self-care with-
out mentioning uncertainty of outcome [ 201; (2) failing to give the patient the benefit of the doubt ; (3) inappropriately attempting to strengthen the patients internal locus of control [23,24] ; and/or (4) using insensitive routines and/or failing to explain why certain questions are asked as part of routine histories [5,25].
In some instances, health care professionals may unwittingly contribute to patients guilt feelings by emphasizing self-care without mentioning the uncer- tainty of the outcome. For instance, Skyler, who encourages his patients to achieve the best diabetes control, notes when writing about diabetic complica- tions: ... we may be faced with the circumstance that despite the patients best efforts, chronic complications may still develop. This may cause the patient to have guilt feelings that there was something that he or she could have done to avert complications. With our present state of knowledge, this is a difficult dilemma, since we must strive for the best possible result with available therapy while not imposing unnecessary burdens either currently or in the future. .
Moreover, as Godley noted, health professionals must avoid equating good control with absence of diabetic complications and bad control with their presence . Persons with chronic complications should not have to deal with health care professionals who deny them the benefit of the doubt, or who blame the victims for their deteriorating medical condition [ 161.
Patient educators may possess attitudes that promote patient guilt through incomplete understanding of health locus of control research. Many investi- gators have assumed that patients beliefs in themselves as responsbile for their health (referred to as an internal locus of control, or internality) should
be strengthened. Wallston and Wallston term this position naive . An internal locus of control is not always in the better interest of patients, partic- ularly if they have no control over their illness. Consider how such an extreme stance could lead to guilt feelings: Rigid beliefs that they, and they alone, could affect their health might inappropriately prevent patients from seeking ade&uate medical attention. Wallston and Wallston note that patients with strong internal health locus of control may, in insisting that they are respon- sible for their illness, put off potential helpers (including health professionals, relatives and friends) who might be all too willing to let the patient assume total responsibility and then turn around and blame the patient if and when things go wrong .
Health professionals may produce shame or guilt in patients almost from the moment their health care begins. Hospitalized patients, for example, may feel ashamed after going through a variety of what Hartmann calls stripping procedures:
loss of status, giving up of personal clothing, acceptance of institutional clothing; depersonal- ization of the surroundings; obliteration of individual differences with regard to fellow patients, exposure to the gaze of others, the feeling of being trapped, not being able to eliminate others from his perceptual field; surren