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Analysis

The burden of shame and stigma

11 March, 2014

The burden of shame and stigma

It is not only women who experience shame and stigma because of their circumstances – it can affect midwives too, as Mary Steen and Alun Jones explain.




Midwives magazine: Issue 2 :: 2014 It is not only women who experience shame and stigma because of their circumstances – it can affect midwives too, as Mary Steen and Alun Jones explain. 

Research has shown that people receiving care in mental health settings can experience feelings of shame and stigma because of their situations (Jones and Crossley, 2008). It shows that those providing the care can be affected too.

The examples of how some women are predisposed to mental ill-health are many. A life event, such as becoming pregnant and deciding to have an abortion, can be a trigger. Another might be choosing to have the baby, but struggling with perceptions of being unfit to provide mothering (Steen and Jones, 2013). 

It is not only women who struggle with such events. Men’s mental health can also be affected by these types of circumstances, along with changes in relationship dynamics because of pregnancy and parenthood.

It may be that an expectant mother feels ambivalent about her pregnancy. If she miscarries or experiences difficulties, she may feel a sense of personal responsibility, together with guilt and shame.

Although seeking professional support for such feelings can be helpful, it can add to the burden. Shame and self-stigmatisation can escalate when a referral is made for an expectant mother or new parent to receive mental health care and psychological therapy (CMACE, 2011; Hessina, 2011).

An extreme example of such stigma and shame is Felicia Boots, who was convicted of manslaughter of her two infant children in 2012. Suffering from severe postnatal depression, she was believed to have hidden the extent of her emotional and psychological distress, and therefore did not receive the care and support she needed (Topping, 2012).

Midwives’ shame
Shame is defined as a universal, adaptive and common emotional response to exposure of easily-hurt aspects of the self. Some people are more vulnerable to it than others (Wiklander et al, 2003). Shame encompasses feelings of being wrong as a person and it can take different forms. It can occur either as self-to-self – that is, in one’s own mind – or from self-to-other, which is shame in the mind of another. Or it can be both (Gilbert and Procter, 2006).

Current emphasis concerns the experiences of clients, which is understandable. But it is likely to be of equal importance that midwives voice their day-to-day work experiences. This is because research suggests that mental health professionals can feel shame and experience stigmatisation because of aspects of their work. This means that midwives could be similarly affected (Jones and Crossley, 2012).

If unchecked, shame and stigma can have a significant impact on both parents and midwife. Expectant parents who are experiencing difficulties with childbirth may become self-absorbed. Critical ruminations are likely to ensue and this can lead to these parents failing to care for themselves appropriately.

Meanwhile, midwives’ professional practice may also become compromised because of shameful ruminations. This can lead to personal discomfort, along with the possibility of overlooking the difficulties faced by others. It may result in feelings of shame influencing client care and team-working when it affects relationships with colleagues. If this happens, the quality of care is compromised, along with professional satisfaction and wellbeing.

Compassionate curriculum
Compassionate care is often insufficiently emphasised in education (Steen and Jones, 2013). To enable midwives to understand and provide compassionate care, good communication skills need to be taught from the outset. Professional compassion, to oneself and colleagues, should feature prominently in students’ preparation for their working life. Knowledge and understanding of sensitive communication will assist them to promote good working relationships and, ultimately, a more caring profession.

At present, it appears that this important element is often neglected in the curriculum and, therefore, in the workplace. Steen (2011) has highlighted that poor working relationships, aggressive behaviour and bullying within the profession are a common phenomenon. It has also been reported that students have either experienced or witnessed intimidation within their clinical or educational environments (Gillen et al, 2009). Urgent attention is needed to address this.

It may be helpful to develop units of study in mental health, emphasising the ‘parity of esteem’ concept to increase awareness that mental health should be treated as seriously as physical health (Steen and Steen, 2014). If clinical placements were included, perhaps on mother and baby units, this could greatly assist student midwives in their understanding of complex communications, which can lead to emotional difficulties concerned with childbirth and parenthood.

If this deficit in education is addressed, it may contribute to enhancing midwives’ professional skills, competencies and abilities to deal with stigma and shame related to direct family care and team-working.

Research
Undertaking exploratory research will help to understand the impact that this may have on women and their families, as well as the effect on midwives themselves.

Research may also help us know more about how shame-provoking events affect expectant parents and midwives. In instances where such parents experience difficulties with pregnancy and childbirth, shame can be invoked in a variety of complex ways. This can then cause self-denigration and negative ruminations. When this happens, it can lead to misunderstandings in vital communications between patient and midwife. Systemically, family groups can also become conflicted as families try to defend against feelings of shame along with stigmatisation that are caused by a family member’s emotional ill-health.

Stigma and shame might therefore impede recovery and adaptation to parenthood when emotional problems occur. Difficulties can be passed across generations. This can happen in a family but also within the profession, so the stakes are high.

It is important that more is understood about the complexities of stigma and shame when they relate to pregnancy and childbirth in different social and cultural settings.

For example, a pregnant woman from Nigeria who had a temporary visa and whose husband abandoned her shortly after arriving in the UK, found it difficult to ask for help as she felt ashamed. After the birth, she was in a very dark place and had no one to support her.
Fortunately, during the postnatal period, trusting relationships were built and a health visitor referred her to a local branch of mental health charity Mind. Her social and cultural needs were considered, she received support and was befriended (Robinson et al, 2013).

A greater understanding of the effects of stigma and shame can help to minimise the negative emotional effects on parents.

Increased knowledge and awareness of communicating emotions effectively may help midwives to organise maternal and family health services in a better way.

Mary Steen
Professor of midwifery, University of Chester, and adjunct professor of midwifery, UniSA, Adelaide

Dr Alun Jones
Visiting professor, University of Chester, and consultant psychotherapist at Yale Spire Hospital, Wrexham



References

CMACE. (2011) Saving mothers’ lives: reviewing maternal deaths to make motherhood safer: 2006-08. The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. Centre for Maternal and Child Enquiries. BJOG 118(Suppl 1): 1-203.

Gilbert P, Procter P. (2006) Compassionate mind training for people with high shame and self-criticism: overview and pilot study of a group therapy approach. Clinical Psychology & Psychotherapy 13(6): 353-79.

Gillen P, Sinclair M, Kernohan GW, Begley C. (2009) Student midwives’ experience of bullying. Evidence-Based Midwifery 7(2): 46-53.

Hessina L. (2011) Stigma, shame and sexuality: a reflection on abortion. See: www.rhrealitycheck.org/blog/2011/09/19/stigma-shame-sexualityreflection-abortion (accessed 12 February 2014).

Jones AC, Crossley DR. (2012) Shame and acute psychiatric inpatient care: healthcare professionals. International Journal of Mental Health Promotion 14(3): 125-38.

Jones A, Crossley D. (2008) In the mind of another – shame and acute psychiatric inpatient care: an exploratory study in progress. Journal of Psychiatric and Mental Health Nursing 15(9): 749-57.

National Treatment Agency for Substance Misuse. (2010) Women in drug treatment: what the latest figures reveal. NTASM: London. See: www.nta.nhs.uk/uploads/ntawomenintreatment22march2010.pdf (accessed 25 February 2014).

Robinson M, Steen M, Roberts S. (2013) Evaluation of the local Mind resilience programme. Interim report. Faculty of Health and Social Sciences, Leeds Metropolitan University, Faculty of Health and Social Care, University of Chester: Leeds and Chester.

Steen M, Steen S. (2014) Striving for better maternal mental health. The Practising Midwife (in press).

Steen M, Jones A. (2013) Stigma and shame concerning maternal mental health. The Practising Midwife (in press).

Steen M. (2011) Conflict resolution for student midwives. The Practising Midwife 14(3): 25-7.

Topping A. (2012) Woman admits killing her two babies. The Guardian. See: www.theguardian.com/uk/2012/oct/30/woman-admits-killing-two-babies (accessed 25 February 2014).

Wiklander M, Samuelsson M, Åsberg M. (2003) Shame reactions after suicide attempt. Scandinavian Journal of Caring Sciences 17(3): 293-300.



 

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