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Shame and acute psychiatric in-patient care

  • David Richard Crossley (a1) and Alun Charles Jones (a1) (a2)
Abstract
Aims and method

To investigate the complementarities of staff and service users' experiences of shame in psychiatric in-patient settings. Qualitative methods were used by means of focus group interviews in two compositions – staff and service users. Data were transcribed and thematically analysed.

Results

Service user group transcripts revealed four prominent themes: ‘loss of value’, ‘loss of adulthood and autonomy’, ‘loss of subjectivity’ and ‘shaming or blaming of others’. Staff group transcripts also revealed two themes one of which overlapped with service users (‘shaming or blaming of others’) and one of which was distinct (‘entrapment’).

Clinical implications

Shame processes may be elicited by caregiving and impede treatment. Staff find themselves in the predicament of provoking the problems they intend to address. Suggestions are made as to how to respond to this dilemma and practically improve aspects of the in-patient care process to reduce shame.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
David Richard Crossley (david.crossley@wales.nhs.uk)
Footnotes
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Declaration of interest

None.

Footnotes
References
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1 Hinshaw, SP. The Mark of Shame Stigma of Mental Illness an Agenda for Change. Open University Press, 2007.
2 Gilbert, P. What is shame? Some core issues and controversies. In Shame Interpersonal Behaviour Psychopathology and Culture (eds Gilbert, P & Andrews, B): 338 Open University Press, 1998.
3 Tangney, JP, Wagner, P, Gramzow, R. Proneness to shame, proneness to guilt and psychopathology. J Abnorm Psychology 1992; 10: 469–78.
4 Pyne, J, Kuc, M, Schroeder, PJ, Fortney, JC, Edlund, M, Sullivan, G. Relationship between perceived stigma and depression severity. J Nerv Ment Dis 2004; 192: 278–83.
5 Gilbert, P, Pehl, J, Allan, S. The phenomenology of shame and guilt: an empirical investigation. Br J Med Psychology 1995; 67: 2336.
6 Lazare, A. Shame and humiliation in the medical encounter Arch Int Med 1987; 147: 1653–8.
7 Bromley, JS, Cunningham, SJ. ‘You don't bring me flowers anymore’: an investigation into the experience of stigma by psychiatric in-patients. Psychiatr Bull 2004; 28: 371–4.
8 Vuokila-Oikkenen, P, Janhonen, S, Nikkonen, M. Patient initiatives in psychiatric care concerning shame in the discussion in cooperative team meetings. J Psychiatr Ment Health Nurs 2002; 9: 2332.
9 Knight, B. Research in Focus: Using Focus Groups in Institutional Research. Conference paper at Bowling Green State University OAIRP Spring Conference, 25 March 2011 (http://www.bgsu.edu/downloads/finance/file95423.pdf).
10 Jones, A, Crossley, D. In the mind of another: shame and acute psychiatric in-patient care: an exploratory study in progress. J Psychiatr Ment Health Nurs 2008; 15: 749–57.
11 Harper, JM, Hoopes, MH. Uncovering Shame: An Approach Integrating Individuals and their Family Systems. Norton, 1990.
12 Sanders, P, Wilkins, P. First Steps in Practitioner Research: A Guide to Understanding and Doing Research in Counselling and Health and Social Care. PCCS Books, 2010.
13 Jones, A, Cutcliffe, J. Listening as a method of addressing psychological distress. J Nurs Manag 2009; 17: 352–8.
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BJPsych Bulletin
  • ISSN: 1758-3209
  • EISSN: 1758-3217
  • URL: /core/journals/bjpsych-bulletin
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Shame and acute psychiatric in-patient care

  • David Richard Crossley (a1) and Alun Charles Jones (a1) (a2)
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eLetters

Shame feelings in a community psychotherapy group

Victoria Cohen, Locum Consultant Psychiatrist
11 January 2012

Crossley and Jones' article on shame and acute psychiatric in-patientcare was of great interest as the themes discussed are pertinent to the psychodynamic group we facilitate in a community rehabilitation service (an open group for patients with psychosis). The patients frequently bringup shame about their illness in different ways. The super ordinate themes they identified are persistent themes within our group.

Patients talk about feeling looked at "differently" by the public when on the streets or using public transport. They question this, wondering whether people can tell that they have a mental illness or whether they are paranoid. Avoiding potential feelings of shame has led toself-isolation and loss of independence for several of our patients.

Patients describe their loss of adulthood and autonomy, especially when admitted to hospital. Their accounts of being cared for by mental health services are full of shameful experiences, such as being restrained. They notice the distance between their current position and apotential future "adulthood", leading to feelings of hope and loss.

Issues regarding medication have obviously featured, including the pride felt in taking the responsibility of self-medicating. They reflect on the stress of taking responsibility against the rewards of achieving goals.Our patients are undoubtedly being observed which, as stated in the paper,inevitably heightens feelings of self-consciousness. The group is able to voice these feelings when considering why they choose not to express opinions on certain topics. They have acknowledged feeling observed by other group members, as well as the facilitators, and the worry about being judged.

The group is developing increased self-worth and protesting against shameful feelings by expressing their concerns. There is compassion in thegroup for one another and a wish to increase each other's feelings of worth. Patients emphatically and movingly encouraged another physically immobilised patient to keep trying to "recover". They stated that it wouldbe painful and he may cry but that he should not be ashamed of it and he would not be judged by them.

The paper helped us to consider the shame we may feel as group facilitators, especially when the group is curious about our lives. Envy of our idealised lives, in and out of work has been present in the group. We feel guilt about how much we are available for them, while they expressconcern about how much they need the group.

Patients in the group have had numerous admissions, with repeated admissions being reported as more shaming. However we would suggest that same feelings of shame may apply to all patients with severe and enduring mental illness not just those in an in-patient setting. Clinicians are often so focussed on the patient's insight we may overlook the emotional potency of feelings of shame regardless of insight. We think it is important to consider shame feelings and ways of expressing them when working with patients with mental illness in any setting.

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Conflict of interest: None declared

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