Not Good Enough: Addressing the Cancer of Clinician Shame

Were you at the last session of the 2015 U.S. Psychiatric and Mental Health Congress? If you were, you undoubtedly remember the experience. It was in that session that my colleagues Rakesh Jain, MD, MPH; Saundra Jain, PsyD, MA, LPC; and Clay Jackson, MD, discussed the difficult topic of clinician suicide. This session, and the question and answer session that followed it, highlighted that not only is clinician suicide a significant issue for our field, but that it is also a deeply personal one. 

Approximately 750 of our fellow physicians, nurses, psychotherapists take their own lives each year, making it imperative that we begin to explore and understand the despair within our ranks. How can it be that the helping professions are failing their own members so dramatically? 

The discussion that followed the session on clinician suicide was telling. People spoke of their long hours on the job, the frustrations in dealing with the insurance companies whom we depend upon to make a living, and the demands placed upon us by our patients and the institutions for which we work. 

But medicine is not the only profession that carries a great burden of responsibility. There are many jobs with similar degrees of demand and burden. What is it about the healthcare profession that is causing so many of our members to take their own lives each year? 

I suspect that one element that contributes to this tragedy is shame. Shame, by definition, is not discussed. Shame differs from guilt because with guilt, one feels badly about what one has done, which means that such transgressions can be corrected through reparative practices and penance. Shame, on the other hand, is deeper. When people feel shame, they feel like something is wrong with them. Not just for what they did, but for who they are.   

The feeling of shame is inexorably linked with fear of exile from the tribe. Shame is often used to enforce the norms of the community. Just look to the back pages of the journal for your state medical, nursing, or psychotherapist association or look on their website where disciplinary actions are listed. There you will find the 21st century digital equivalent of the stocks, where colleagues who transgressed enough to lose their licenses are held out as an example to others. 

But this rare kind of transgression is not the kind of shame to which I’m referring. I'm talking about the small, incremental experiences that we have all had that corrode our sense of well-being and confidence. I'm talking about those repeated small humiliations that we all suffered in training. They likely came from a well-intentioned, elder mentor but were ultimately destructive. I'm talking about the accretion of the wounds from microaggressions and slights that we continue to suffer from (and probably unknowingly, we also inflict on others) our colleagues with regularity. 

These shame experiences eventually grow into a kind of cancer that, like carcinoma, destroys from the inside out. In a vicious cycle, the shamed person becomes smaller, feels more alone in the world, and feels less worthy of help. Shame sets the stage for isolation and depression. Unable to seek help, the person views alcohol and substance use as appealing refuges. The ultimate expression of shame and isolation is suicide. 

A core feature of shame is the feeling of "not being good enough." How many of us have suffered from this feeling? If you have a PhD or a PsyD, how many times have you been told "oh, you're not an ‘actual doctor’". How many of my psychiatrist colleagues have been asked, “why didn't you go into some ‘real’ area of medicine?” How many of my nurse colleagues have been told that we are not good enough, so we attempt to prove our worth with a cryptic string of credentials following our names? How many LCSW, MFT, or LPCC colleagues have been told that their skills are not as important as those of a doctorally trained therapist? 

I believe our efforts are better spent in finding commonality among colleagues rather than differences. What if we agreed that our training models should teach our young colleagues to become smart, tough, but also compassionate and humane? What if we agreed to do away with the horizontal violence and traditions of bullying, hazing, and disrespect that we see within and between our professions? What if we made a commitment to care for each other as much as we care for patients? 

And while we are working towards being kinder to one another, can we begin to work towards being kinder to ourselves? I suspect that most of us are harder on ourselves than any mentor could ever be. There is a great burden that we have chosen to carry in this profession. Need we make this burden greater by having unrealistic expectations of what one person can do and expecting ourselves to be superheroes? When we cast ourselves, or allow ourselves to be cast, in the role of superman and superwoman, everyone expects that we can fly. People are only surprised when superman can't fly. 

I’ll be back in part 2 of this blog entry to talk about how we can begin to take better care of ourselves and each other, but I’m more interested in hearing what you have to say. Please take a moment and add your thoughts in the comments below. I’d love to hear about the experiences that hurt you and also the experiences on your path to where you are today that made you stronger and more compassionate. Let’s start taking care of each other as well as we take care of our patients. Let it start with us. 

Andrew Penn was trained as an adult nurse practitioner and psychiatric clinical nurse specialist at the University of California, San Francisco. He is board certified as an adult nurse practitioner and psychiatric nurse practitioner by the American Nurses Credentialing Center. Currently, he serves as an Assistant Clinical Professor at the University of California-San Francisco School of Nursing. Mr. Penn is a psychiatric nurse practitioner with Kaiser Permanente in Redwood City, CA, where he provides psychopharmacological treatment for adult patients and specializes in the treatment of affective disorders and PTSD. He is a former board member of the American Psychiatric Nurses Association, California Chapter, and has presented nationally on improving medication adherence, emerging drugs of abuse, treatment-resistant depression, diagnosis and treatment of bipolar disorder, and the art and science of psychopharmacologic practice. 

The views expressed on this blog are solely those of the blog post author and do not necessarily reflect the views of Psych Congress Network or other Psych Congress Network authors. Blog entries are not medical advice.