In 2016 a group of Sweden researchers developed an interesting study, and relative paper, concerning the connection between abuse, shame, healthcare, medical staff and patients.[1]
The team developed and evaluated a pedagogical model for staff interventions using Forum Play, focusing on staff’s experiences of failed encounters where they have perceived that the patient felt abused. During and after the intervention, five important lessons were learned and incorporated in the theoretical framework. First, a Forum Play intervention may break the silence culture that surrounds abuse in health care. Second, organizing staff training in groups was essential and transformed abuse from being an individual problem inflicting shame into a collective responsibility. Third, initial theoretical concepts “moral resources” and “the vicious violence triangle” proved valuable and became useful pedagogical tools during the intervention. Four, the intervention can be understood as having strengthened staff’s moral resources. Five, regret appeared to be an underexplored resource in medical training and clinical work.
Galtung’s “vicious violence triangle” uses the analogy of the three corners of a triangle, which all three have to be in place to form a triangle, to illustrate how one corner, depicting direct events of violence, cannot be understood without at the same time also analysing the two other corners; depicting structural and cultural violence.
To understand how the violence triangle operates on an individual level they turned to works in moral philosophy and found Glover’s thorough analysis of how “ordinary people” can perform inhumane deeds, portrayed in his book Humanity. In short, Glover finds that it is the erosion of people’s moral resources (respect, sympathy, and moral identity) that may lead them to perform inhumane deeds. When applied to health care these mechanisms would include the fragmentation of responsibility, distancing to others, fear, the imposition of a belief-system, or moral slide. Any of these mechanisms can override and distort health care staff’s moral resources.
When shame operates without being acknowledged as such or properly named, it often creates behaviours that may seem inexplicable. For patients the need of secure bonding to an important care giver is evident and the threat when bonding does not work is alienation, which easily is followed by shame. For both parts, if shame is acknowledged as such, functional communication can occur and cooperation can take place concerning what happened and what could be done to find a way out. However, when shame is unacknowledged, it easily creates intense reactions, anger or other types of disrespectful behaviour, which will disturb the communication and possibilities to cooperate. Disrespectful behaviour by one party is prone to create shame in the other, who may react in a disrespectful way, and there is a risk of vicious loop. When shame is acknowledged, on the other hand, respectful reactions may be the consequence and constructive cooperation more easily found.
However, there may be other reactions to unacknowledged shame than attacking others. A patient emerged in a case had used avoidance all his life, until the confrontation in the delivery room led to a breakdown of that strategy when he was drowned in his unacknowledged shame, and attacking others instead became his main strategy. This behaviour was totally inexplicable to the health care staff. The final result of this conflict, which was based on unacknowledged shame by both parties, was – silence. Shame and silence are so intertwined.
When staff had the opportunity to work together in groups and find alternative ways of acting against AHC (abuse in healthcare), they together created a climate during the study period in which AHC was recognized, much talked about and deemed unacceptable.
What happened during and after the intervention can be described as:
- the silence culture surrounding AHC was broken;
- training staff in groups was essential and made it possible to transform AHC from an individual problem inflicting shame to a group responsibility;
- “moral resources” and “the vicious violence triangle” became useful pedagogic tools in the intervention,
- moral resources were strengthened during the study period, and
- regret appeared to be an unexplored resource in medical training and clinical work.
As complex reactions take place when AHC occurs, there is an urgent need of theoretical development within the research field.
[1] Wijma B, Zbikowski A, Brüggemann AJ. Silence, shame and abuse in health care: theoretical development on basis of an intervention project among staff. BMC Medical Education. 2016
