People with complex lives and complex needs related to homelessness or other severe disadvantage are no strangers to shame. Many will have experienced judgement regarding their economic situation, literacy, personal habits such as smoking, and the fact that they may be living in a hostel or even on the streets. It can be difficult for them to maintain personal standards of hygiene and appearance, leading to generalised feelings of failure, exclusion and stigma. Many will not have had the opportunity to see a dentist for many years, and the longer that goes on the harder it may become practically and emotionally. What little pride is left may result in avoidance behaviours that are stronger than the pull of any wish for treatment, and evoke mental pain that is stronger than any physical pain experienced. Shame can lead to panic, which in turn may contribute to denial and avoidance.
People affected by homelessness learn to be closed about their personal circumstances. So much of their lives is lived in public, and involves disclosures to support workers, benefits agents etc. When something can be kept private, it is tempting to do so. And when disclosure would likely invoke embarrassment and shame, as with bad teeth, a downward spiral of concealment and neglect can be triggered. This may continue until dental pain and infection reach such a level that they can no longer be ignored. Urgent treatment may itself be a traumatic and acutely shameful experience when accompanied by insensitive comments such as: “Well you should have looked after your teeth if you didn’t want them out”. This can perpetuate the cycle of isolation and alienation typical of a life impacted by homelessness.
We are often judged on first appearances. Indeed, our language is replete with idioms that reflect appearance as a key component of identity – face value, saving or losing face, putting on a brave face etc. The face is how we recognise people, communicate verbally and express our feelings. If that face is flawed, the impact is massive and can give a sense of heightened visibility – the only thing noticed by others. Many patients are desperately and chronically ashamed of missing, decayed or broken front teeth. Some have suffered years of infection and severe pain, choosing this as preferable to the greater shame of having no front teeth. Whilst scars might tell a story of courage, bad teeth overwhelmingly say “neglect”.
Against a background of chronic shame, a visit to the dentist for the first time in many years may provoke anticipation of an acutely shaming and anxiety-inducing experience. Patients may avoid clinical encounters if they fear being shamed, raising a significant barrier to engagement with treatment. Conversely to this, evaluation has also shown that shame and embarrassment around the condition of someone’s teeth can also be a motivation for them to seek care (Paisi et al., 2019), indicating that the effects of shame can be complex. When patients attend their first appointment, they are often terrified of being judged due to the condition of their teeth. In our experience, this fear seems more apparent than fear of dental procedures or needles. Some patients have self-medicated with drugs/alcohol to feel able to attend appointments, and this can be an additional source of shame in the moment. Yet, missing appointments can lead to feelings of further shame.
The likelihood is that patients with serious, and especially with disfiguring dental problems may feel a tangle of emotions at that first encounter with a dentist– shame plus guilt, embarrassment and fear. It is not difficult to see which of these – fear – is the most socially acceptable and, consequently, easiest to admit to. It makes sense to look behind this and think are they also feeling embarrassed and ashamed at their appearance, and feeling guilty for their self-neglect. This matters if it conditions the dentist’s response. Efforts to allay fear can signal a wider compassionate approach, but if all emphasis is placed on fear triggers – the noise of the drill, fear of pain, or needles – then an opportunity may be lost for putting the patient at ease. Direct questions are likely to be counterproductive, but it is likely to be helpful to anticipate such concerns and provide reassurance that the dentist is not in any way judgemental or surprised at the state of the patient’s mouth and is only focused on helping.
The shame patients feel may be for multiple reasons: for how their teeth look; “I never smile showing my teeth”; for not seeking help – “my mouth is disgusting, I don’t want you to see”; for not performing oral self-care – “I can’t even brush my teeth every day”; and for use of drugs or alcohol – “I had nice teeth until I was a junkie”. Other experiences including suffering from bulimia or being the victim of domestic violence may also be visible in the teeth, provoking their own associated feelings of shame.
Socioeconomic and environmental factors are prominent in discussions of determinants of health, but there has been little acknowledgement of the impact of shame on health outcomes. Yet it can have direct effects through stress-related immune and endocrine responses. Behaviours triggered by shame may contribute to denial of the need for help and avoidance of opportunities for intervention, with the consequence that conditions deteriorate. Inequalities may be played out through poor health choices including coping strategies adding to the burden of harm. Thus, many people who have experienced homelessness use drugs or alcohol to deal with the physical pain of toothache as well as the psychological pain of their situation.
Understanding trauma, the impact that it has on patients, and the way that this can be manifested through shame, has informed the approach that we take with vulnerable patients. This is developed in our next blog post on the steps we have taken to be shame-sensitive.
Christina Worle, PDSE Dentist, Peninsula Dental Social Enterprise CIC – Christina.firstname.lastname@example.org
Lyndsey Withers, Community Volunteer – email@example.com
Paisi, M., Witton, R., Burrows, M., Allen, Z., Plessas, A., Withers, L., McDonald, L. & Kay, E. (2019) ‘Management of plaque in people experiencing homelessness using ‘peer education’: a pilot study’. British Dental Journal, 226 (11),pp. 860-866.
We have been inspired to write this article by Dolezal, L. (2015) ‘The Phenomenology of Shame in the Clinical Encounter.’
Excellent resources on trauma informed dentistry were commissioned from Victim Focus by the Faculty for Homeless and Inclusion Health Oral Health Subgroup and HEE and are available here: https://www.pathway.org.uk/publication/trauma-informed-dentistry-care/.
The success of the PDSE Community Dental Clinic is due to the dedicated contributionsof the entire team including Robert Witton, Chief Executive of Peninsula Dental Social Enterprise (PDSE), Martha Paisi,PDSE Research Lead, and the and nursing and administrative colleagues who all contribute to the excellent patient care we aim to provide.